Provider Demographics
NPI:1467282020
Name:POVICH, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:POVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 BISON HILL LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5010
Mailing Address - Country:US
Mailing Address - Phone:919-607-0839
Mailing Address - Fax:
Practice Address - Street 1:8832 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6809
Practice Address - Country:US
Practice Address - Phone:980-446-3567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20162101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health