Provider Demographics
NPI:1811350796
Name:MARBURY, JERETHA NA
Entity type:Individual
Prefix:MS
First Name:JERETHA
Middle Name:NA
Last Name:MARBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JERETHA
Other - Middle Name:NA
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 71320
Mailing Address - Street 2:JERETHA MARBURY
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:28307-1320
Mailing Address - Country:US
Mailing Address - Phone:253-376-6503
Mailing Address - Fax:
Practice Address - Street 1:201 S MCPHERSON CHURCH RD STE 202D
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4974
Practice Address - Country:US
Practice Address - Phone:253-376-6503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172V00000X, 1744R1102X, 373H00000X, 171M00000X, 171WH0202X
WA390200000X, 146D00000X
171R00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker
No1744R1102XOther Service ProvidersSpecialistResearch Study
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171R00000XOther Service ProvidersInterpreter
No171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346613387Medicaid