Provider Demographics
NPI:1932609187
Name:STUTTS PACK, JENNIFER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STUTTS PACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:4002 EXECUTIVE PARK BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9069
Mailing Address - Country:US
Mailing Address - Phone:910-477-6236
Mailing Address - Fax:910-477-6357
Practice Address - Street 1:4002 EXECUTIVE PARK BLVD STE 800
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9069
Practice Address - Country:US
Practice Address - Phone:910-477-6236
Practice Address - Fax:910-477-6357
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist