Provider Demographics
NPI:1255697371
Name:CROCKETT, JAMIE (MS, LPCA)
Entity type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603B NEW GARDEN VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8595
Mailing Address - Country:US
Mailing Address - Phone:336-272-8090
Mailing Address - Fax:
Practice Address - Street 1:5603B NEW GARDEN VILLAGE DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8595
Practice Address - Country:US
Practice Address - Phone:336-272-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPCA# A9026101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor