Provider Demographics
NPI:1619366291
Name:JUNGCLAS, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:JUNGCLAS
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 1:102 SPRING BUD DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3543
Mailing Address - Country:US
Mailing Address - Phone:919-605-5388
Mailing Address - Fax:
Practice Address - Street 1:102 SPRING BUD DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-3543
Practice Address - Country:US
Practice Address - Phone:919-605-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer