Provider Demographics
NPI:1871632430
Name:FUNDERBURG, JAMARR J (LCSW, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:JAMARR
Middle Name:J
Last Name:FUNDERBURG
Suffix:
Gender:M
Credentials:LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 J N PEASE PL STE 202
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4539
Mailing Address - Country:US
Mailing Address - Phone:704-771-4633
Mailing Address - Fax:
Practice Address - Street 1:1905 J N PEASE PL STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4539
Practice Address - Country:US
Practice Address - Phone:704-771-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1184101YA0400X
NCC0055991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1184OtherLCAS
NCC005599OtherLCSW