Provider Demographics
NPI:1912498858
Name:WHITE, JESSE STEPHEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:STEPHEN
Last Name:WHITE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 BLACKROCK RD
Mailing Address - Street 2:
Mailing Address - City:MERRY HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27957-9691
Mailing Address - Country:US
Mailing Address - Phone:252-325-4535
Mailing Address - Fax:
Practice Address - Street 1:2275 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27537-8732
Practice Address - Country:US
Practice Address - Phone:252-492-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-26
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5728225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty