Provider Demographics
NPI:1275009698
Name:KING, JESSICA RIDENHOUR
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RIDENHOUR
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 FAITH WAY RD
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-8868
Mailing Address - Country:US
Mailing Address - Phone:336-263-3130
Mailing Address - Fax:
Practice Address - Street 1:5705 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5318
Practice Address - Country:US
Practice Address - Phone:919-424-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9885224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant