Provider Demographics
NPI:1104218106
Name:HEPHNER, JACQUELYN M (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:HEPHNER
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:M
Other - Last Name:BORDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M ED, LAT, ATC
Mailing Address - Street 1:104 RICHLAND DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-9274
Mailing Address - Country:US
Mailing Address - Phone:937-654-1414
Mailing Address - Fax:
Practice Address - Street 1:104 RICHLAND DR
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27596-9274
Practice Address - Country:US
Practice Address - Phone:937-654-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer