Provider Demographics
NPI:1730565052
Name:DODGE-EVANS, JAQUELIN (LPCA)
Entity type:Individual
Prefix:
First Name:JAQUELIN
Middle Name:
Last Name:DODGE-EVANS
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2841
Mailing Address - Country:US
Mailing Address - Phone:252-439-0700
Mailing Address - Fax:252-439-0900
Practice Address - Street 1:2269 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2841
Practice Address - Country:US
Practice Address - Phone:252-439-0700
Practice Address - Fax:252-439-0900
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional