Provider Demographics
NPI:1992376248
Name:ATCHISON, JACK DALLAS II
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DALLAS
Last Name:ATCHISON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PENDER LN
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-6817
Mailing Address - Country:US
Mailing Address - Phone:336-255-0947
Mailing Address - Fax:
Practice Address - Street 1:1111 PENDER LN
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-6817
Practice Address - Country:US
Practice Address - Phone:336-255-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant