Basic Information
| Provider Information | |||||||||
| NPI: | 1215492624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUTHARD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 NC 65 | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273208882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363428316 | ||||||||
| FaxNumber: | 3363428330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | A14633 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.