Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 12191 | NC |
NPI | 1003140872 |
---|---|
Provider Name | Jenna King |
First Address | New Bern, NC 28560-3449 |
Second Address | New Bern, NC 28560-3449 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2009 |
Last Update Date | 28/09/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
018TE | BLUE CROSS (01) | NC |