Provider Demographics
NPI:1902482029
Name:BALDWIN, JASARAH NICOLE (LCASA, LCMHCA)
Entity Type:Individual
Prefix:
First Name:JASARAH
Middle Name:NICOLE
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:LCASA, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 MCPHAIL RD APT 3D
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-8024
Mailing Address - Country:US
Mailing Address - Phone:910-366-9927
Mailing Address - Fax:910-618-0728
Practice Address - Street 1:3750 MEADOW VIEW RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-1920
Practice Address - Country:US
Practice Address - Phone:910-618-9912
Practice Address - Fax:910-618-0728
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26460101YA0400X
NCA16375101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0727Medicaid