Provider Demographics
NPI:1811277098
Name:DAVENPORT, JACQUELINE MARIE (PT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:DELGIORNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:103 N MAIN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2796
Mailing Address - Country:US
Mailing Address - Phone:864-528-5700
Mailing Address - Fax:864-528-5701
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:STE C250
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-0952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist