Provider Demographics
NPI:1801382668
Name:DITTER, JACLYN J (MS,LPC-A, LCAS-A)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:J
Last Name:DITTER
Suffix:
Gender:F
Credentials:MS,LPC-A, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 BALLENA CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-4958
Mailing Address - Country:US
Mailing Address - Phone:608-558-1907
Mailing Address - Fax:
Practice Address - Street 1:130 PRESTON EXECUTIVE DR STE 102
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8433
Practice Address - Country:US
Practice Address - Phone:608-558-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24369101YA0400X
NCA14059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)