Provider Demographics
NPI:1902336092
Name:DAVIS, JESSICA LYNN ROEBUCK (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN ROEBUCK
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 S HORNER BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-5717
Mailing Address - Country:US
Mailing Address - Phone:919-718-5408
Mailing Address - Fax:919-774-3155
Practice Address - Street 1:2300 REXWOODS DR STE 140
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3361
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0115521041C0700X
NCC0133221041C0700X
NCLCAS-23854101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)