Provider Demographics
NPI:1801374731
Name:MATLOCK, JESSICA (LPCA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 GOLDEN GATE DR STE B
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5619
Mailing Address - Country:US
Mailing Address - Phone:336-429-5600
Mailing Address - Fax:336-429-5600
Practice Address - Street 1:2110 GOLDEN GATE DR STE B
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5619
Practice Address - Country:US
Practice Address - Phone:336-429-5600
Practice Address - Fax:336-429-5600
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14153101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health