Provider Demographics
NPI:1548821895
Name:FAULKENBERRY, JESSICA (MED/EDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FAULKENBERRY
Suffix:
Gender:F
Credentials:MED/EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 ROCKY SLOPE RD APT 1605
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3958
Mailing Address - Country:US
Mailing Address - Phone:803-804-6864
Mailing Address - Fax:
Practice Address - Street 1:880 S PLEASANTBURG DR STE 4F
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2453
Practice Address - Country:US
Practice Address - Phone:864-326-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6827101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor