Provider Demographics
NPI:1982346201
Name:JACKSON, JENNIFER WHITENER (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WHITENER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 PHAESON PL
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-7765
Mailing Address - Country:US
Mailing Address - Phone:828-234-3680
Mailing Address - Fax:
Practice Address - Street 1:2778 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-8028
Practice Address - Country:US
Practice Address - Phone:910-270-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2526225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant