Provider Demographics
NPI:1437534914
Name:THOMPSON, JEWELL (MS, QMHP, CADC, PSS)
Entity type:Individual
Prefix:MISS
First Name:JEWELL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MS, QMHP, CADC, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2166 GOLD HILL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-9351
Mailing Address - Country:US
Mailing Address - Phone:704-819-0464
Mailing Address - Fax:803-973-0207
Practice Address - Street 1:436 E 36TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-1030
Practice Address - Country:US
Practice Address - Phone:704-819-0464
Practice Address - Fax:803-973-0207
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NC2023-10462-01175T00000X
NC25110101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist