Provider Demographics
NPI:1922374560
Name:NILES, JENNIFER ANNE (LCAS, LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:NILES
Suffix:
Gender:F
Credentials:LCAS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 ORANGE FACTORY RD
Mailing Address - Street 2:
Mailing Address - City:BAHAMA
Mailing Address - State:NC
Mailing Address - Zip Code:27503-9182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 ORANGE FACTORY RD
Practice Address - Street 2:
Practice Address - City:BAHAMA
Practice Address - State:NC
Practice Address - Zip Code:27503-9182
Practice Address - Country:US
Practice Address - Phone:919-610-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2212101YA0400X
NCC0091941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical