Provider Demographics
NPI:1184984510
Name:BETHEA, JASMINE SHAVON (LCAS-A)
Entity type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:SHAVON
Last Name:BETHEA
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 OWEN ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-4356
Mailing Address - Country:US
Mailing Address - Phone:919-824-0155
Mailing Address - Fax:
Practice Address - Street 1:5 ONYX CT
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2680
Practice Address - Country:US
Practice Address - Phone:919-408-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320900000X
NCLCAS-28029101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities