Provider Demographics
NPI:1801068440
Name:LILE, JESSE JACOB (MA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:JACOB
Last Name:LILE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4437
Mailing Address - Country:US
Mailing Address - Phone:336-722-8235
Mailing Address - Fax:
Practice Address - Street 1:5000 COUNTRY CLUB RD.
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104
Practice Address - Country:US
Practice Address - Phone:336-714-5478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6731101YP2500X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist