Provider Demographics
NPI:1851715171
Name:WALLACE, JOCELYN JONES (LCAS-A, LPC-A)
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:JONES
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCAS-A, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 MARYLAND DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-9107
Mailing Address - Country:US
Mailing Address - Phone:919-223-3202
Mailing Address - Fax:
Practice Address - Street 1:1203 KENT RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1977
Practice Address - Country:US
Practice Address - Phone:919-797-9544
Practice Address - Fax:919-803-0992
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20038101YA0400X
NCA10754101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional