Provider Demographics
NPI:1659687424
Name:GREENE, JACK CLAYTON (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:CLAYTON
Last Name:GREENE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1492
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1492
Mailing Address - Country:US
Mailing Address - Phone:919-557-3100
Mailing Address - Fax:919-557-3177
Practice Address - Street 1:100 FITNESS DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7263
Practice Address - Country:US
Practice Address - Phone:919-557-3100
Practice Address - Fax:919-557-3177
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist