Provider Demographics
NPI:1912428038
Name:GEORGE, JEREMY MICHAEL (MA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:GEORGE
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 1:2616 BROADLANDS DRIVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604
Mailing Address - Country:US
Mailing Address - Phone:919-901-9632
Mailing Address - Fax:
Practice Address - Street 1:1601 JONES FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-0002
Practice Address - Country:US
Practice Address - Phone:919-851-1527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750539516Medicaid