Provider Demographics
NPI:1821249541
Name:PERNELL, LEON JACKSON SR (LCAS)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:JACKSON
Last Name:PERNELL
Suffix:SR
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 S GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-4571
Mailing Address - Country:US
Mailing Address - Phone:252-430-8774
Mailing Address - Fax:252-430-8821
Practice Address - Street 1:804 S GARNETT ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4571
Practice Address - Country:US
Practice Address - Phone:252-430-8774
Practice Address - Fax:252-430-8821
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)