Provider Demographics
NPI:1013066414
Name:CREDLE, JENNIFER CARTER (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CARTER
Last Name:CREDLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 RIDGEPINE DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-7934
Mailing Address - Country:US
Mailing Address - Phone:919-363-5000
Mailing Address - Fax:919-363-5346
Practice Address - Street 1:3100 NC HWY 55
Practice Address - Street 2:SUITE 102
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-8427
Practice Address - Country:US
Practice Address - Phone:919-363-5000
Practice Address - Fax:919-363-5346
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2215225100000X
NCP2215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0786IOtherBCBS PROVIDER NUMBER
NC7207861Medicaid