Provider Demographics
NPI:1639841067
Name:BINGHAM, JACQUELYN MARIE (OTD, R/L)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:OTD, R/L
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:BINGHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTD, R/L
Mailing Address - Street 1:4451 VILANA RDG APT 403
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4681
Mailing Address - Country:US
Mailing Address - Phone:484-723-3258
Mailing Address - Fax:
Practice Address - Street 1:604 LUCAS RD
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-6623
Practice Address - Country:US
Practice Address - Phone:910-891-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14569OtherNORTH CAROLINA BOARD OF OCCUPATIONAL THERAPY