Provider Demographics
NPI:1811539786
Name:STATON, JESSEYETTA LAVETTA (LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:JESSEYETTA
Middle Name:LAVETTA
Last Name:STATON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:JESSEYETTA
Other - Middle Name:LAVETTA
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7110 LOWEN RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0194
Mailing Address - Country:US
Mailing Address - Phone:704-615-4183
Mailing Address - Fax:
Practice Address - Street 1:2015 AYRSLEY TOWN BLVD STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4068
Practice Address - Country:US
Practice Address - Phone:888-547-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0141851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical