Provider Demographics
NPI:1821495565
Name:BANKS, JACQUELINE KIM (HIS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KIM
Last Name:BANKS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 WESCOTT DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614
Mailing Address - Country:US
Mailing Address - Phone:864-980-6768
Mailing Address - Fax:864-980-6768
Practice Address - Street 1:2537 S SAUNDERS ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2843
Practice Address - Country:US
Practice Address - Phone:919-856-4565
Practice Address - Fax:919-856-4565
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02617237700000X
NC1465237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist