Provider Demographics
NPI:1306724554
Name:SOUDERS, JENNIFER L (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SOUDERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ASHLEY KING RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445-8810
Mailing Address - Country:US
Mailing Address - Phone:216-457-7060
Mailing Address - Fax:
Practice Address - Street 1:18676 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-4049
Practice Address - Country:US
Practice Address - Phone:910-821-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22328225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist