Jan Mallory Tate, LCSW, MED, CSOTP

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

C012511 Issued in NC

Practice address

105 E Center St Ste B-7
Mebane, NC 27302-2420

Phone

(917) 773-8283

Fax

(919) 551-8711

NPI assigned

Sep 28, 2017

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Education

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1506556800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1666051200000",
    "number": "1508375973",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "192 PEMBERTON ST",
            "city": "YANCEYVILLE",
            "state": "NC",
            "postal_code": "273798008",
            "telephone_number": "917-773-8283"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 E CENTER ST STE B-7",
            "city": "MEBANE",
            "state": "NC",
            "postal_code": "273022420",
            "telephone_number": "917-773-8283",
            "fax_number": "919-551-8711"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "105 E Center St Ste B-13",
            "address_purpose": "LOCATION",
            "city": "Mebane",
            "state": "NC",
            "postal_code": "273022420",
            "country_code": "US",
            "telephone_number": "917-773-8283",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1415 W Nc Highway 54 Ste 121",
            "address_purpose": "LOCATION",
            "city": "Durham",
            "state": "NC",
            "postal_code": "277075578",
            "country_code": "US",
            "telephone_number": "919-401-2933",
            "fax_number": "919-401-2994",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TATE",
        "first_name": "JAN",
        "middle_name": "MALLORY",
        "credential": "LCSW, MED, CSOTP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-09-28",
        "last_updated": "2022-10-18",
        "certification_date": "2022-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NC",
            "license": "C012511",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NC",
            "license": "P011313",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NC",
            "license": "C012511",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LCSW LICENSE NUMBER",
            "identifier": "C012511",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Social Worker in Mebane, NC
• Providers in Mebane, NC by specialty
• Clinical Social Worker in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.