Provider Demographics
NPI:1538113212
Name:KEITH, JENNIFER B (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:KEITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S FRANKLIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2799
Mailing Address - Country:US
Mailing Address - Phone:919-556-1700
Mailing Address - Fax:919-556-1245
Practice Address - Street 1:900 S FRANKLIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2799
Practice Address - Country:US
Practice Address - Phone:919-556-1700
Practice Address - Fax:919-556-1245
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant