Provider Demographics
NPI:1487133351
Name:COASTAL RIDGE HEALTH SERVICES, PLLC
Entity type:Organization
Organization Name:COASTAL RIDGE HEALTH SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:JENKS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP-BC, FNP
Authorized Official - Phone:910-821-1418
Mailing Address - Street 1:14057 US HIGHWAY 17 STE 200
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-3793
Mailing Address - Country:US
Mailing Address - Phone:910-821-1418
Mailing Address - Fax:866-860-0997
Practice Address - Street 1:14057 US HIGHWAY 17 STE 200
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-3793
Practice Address - Country:US
Practice Address - Phone:910-821-1418
Practice Address - Fax:866-860-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-10
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LF0000X
NC5009986363LP0808X
NC4461S101YP2500X
VA0024175505363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024175505OtherVIRGINIA NP NUMBER
NC4461SOtherNORTH CAROLINA BOARD OF PROFESSIONAL COUNSELORS
NC5009986OtherNORTH CAROLINA LICENSE NUMBER