Provider Demographics
NPI:1447529466
Name:SWANN, JACYNTHIA
Entity type:Individual
Prefix:
First Name:JACYNTHIA
Middle Name:
Last Name:SWANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MORSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1559
Mailing Address - Country:US
Mailing Address - Phone:919-607-2044
Mailing Address - Fax:
Practice Address - Street 1:405 MORSON ST STE A
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1559
Practice Address - Country:US
Practice Address - Phone:919-607-2044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103TM1800X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC900780474Medicaid