Provider Demographics
NPI:1851535678
Name:ALDRIDGE, JACQUELINE A (MA, LPC, RPT, NCC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:ALDRIDGE
Suffix:
Gender:F
Credentials:MA, LPC, RPT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24458
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4458
Mailing Address - Country:US
Mailing Address - Phone:336-659-8202
Mailing Address - Fax:336-659-8206
Practice Address - Street 1:1311 WESTBROOK PLAZA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1327
Practice Address - Country:US
Practice Address - Phone:336-659-8202
Practice Address - Fax:336-659-8206
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6969OtherSTATE LICENSE