Provider Demographics
NPI:1972232072
Name:REDMOND, JACQUELYN SYDNEY (MS, LCAS, LCMHCA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SYDNEY
Last Name:REDMOND
Suffix:
Gender:F
Credentials:MS, LCAS, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E 36TH ST APT WW327
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1790
Mailing Address - Country:US
Mailing Address - Phone:856-470-6388
Mailing Address - Fax:
Practice Address - Street 1:11403 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-0408
Practice Address - Country:US
Practice Address - Phone:704-368-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17581101YM0800X
NC28148101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty