Provider Demographics
NPI:1730717448
Name:HARRIS, JACQUELINE (LCMHC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4708 MALLARD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-2782
Mailing Address - Country:US
Mailing Address - Phone:336-707-9677
Mailing Address - Fax:
Practice Address - Street 1:4708 MALLARD CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-2782
Practice Address - Country:US
Practice Address - Phone:336-707-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-2686101YA0400X
101YM0800X
NC16915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)