Provider Demographics
NPI:1033916135
Name:GAILEY, JACIE MADISON (LCMHCA)
Entity type:Individual
Prefix:
First Name:JACIE
Middle Name:MADISON
Last Name:GAILEY
Suffix:
Gender:
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6849 FAIRVIEW RD STE 702
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3393
Mailing Address - Country:US
Mailing Address - Phone:980-308-4500
Mailing Address - Fax:
Practice Address - Street 1:6849 FAIRVIEW RD STE 702
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3393
Practice Address - Country:US
Practice Address - Phone:980-308-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20391101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health