Provider Demographics
NPI:1043330020
Name:JENKINS, KELLY SHAFFER (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SHAFFER
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 SPRING FIELD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8356
Mailing Address - Country:US
Mailing Address - Phone:252-443-2766
Mailing Address - Fax:
Practice Address - Street 1:143 NASHVILLE COMMONS DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-1284
Practice Address - Country:US
Practice Address - Phone:252-459-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7201148Medicaid
75289OtherBCBS
2503761BMedicare PIN
75289OtherBCBS
NC7201148Medicaid