| NPI | 1083801781 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JAKE E RICKETSON Licensed Psychologist 336-887-7350 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NC 1167) |
| Enumeration Date | 2007-09-27 |
| Last Update Date | 2008-06-30 |