Provider Demographics
NPI:1023197373
Name:DESILVER, JENNIFER (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DESILVER
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 FALLS RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-1109
Mailing Address - Country:US
Mailing Address - Phone:443-896-6834
Mailing Address - Fax:
Practice Address - Street 1:120 HEALTHPLEX WAY
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502
Practice Address - Country:US
Practice Address - Phone:919-350-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21867225100000X
PAPT019257225100000X
NC18078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG02650P01Medicare PIN