Provider Demographics
NPI:1639591753
Name:FAWCETT, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FAWCETT
Suffix:
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 1:411 BILLINGSLEY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1066
Mailing Address - Country:US
Mailing Address - Phone:704-377-7099
Mailing Address - Fax:704-377-7983
Practice Address - Street 1:411 BILLINGSLEY RD STE 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1066
Practice Address - Country:US
Practice Address - Phone:704-377-7099
Practice Address - Fax:704-377-7983
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1891869780Medicaid
NC1891869780Medicaid