Basic Information
| Provider Information | |||||||||
| NPI: | 1073816534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BA | ||||||||
| FirstName: | JEREEL | ||||||||
| MiddleName: | WILLIAMS | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4707 TANGLEWOOD OAKS ST | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276103159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195396162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2216 S MIAMI BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277036284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198060509 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2010 | ||||||||
| LastUpdateDate: | 12/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C006880 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.