Provider Demographics
NPI:1770868887
Name:KING, JESSICA MARTIN (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARTIN
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:120 WILLIAM PENN PLZ
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2150
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-313-1276
Practice Address - Street 1:11550 COMMON OAKS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7298
Practice Address - Country:US
Practice Address - Phone:919-453-5740
Practice Address - Fax:919-453-5741
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC13356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13356OtherNC PT LICENSE NUMBER