Provider Demographics
NPI:1730893983
Name:WATERS, JESSICA LYN (LCMHCA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:WATERS
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7200
Mailing Address - Country:US
Mailing Address - Phone:704-237-4042
Mailing Address - Fax:
Practice Address - Street 1:705 PENINSULA DR
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7200
Practice Address - Country:US
Practice Address - Phone:704-237-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18438101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional