1104218106 NPI number — JACQUELYN M HEPHNER M.ED, LAT, ATC

Table of content: JACQUELYN M HEPHNER M.ED, LAT, ATC (NPI 1104218106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104218106 NPI number — JACQUELYN M HEPHNER M.ED, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEPHNER
Provider First Name:
JACQUELYN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED, LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BORDA
Provider Other First Name:
JACQUELYN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M. ED, LAT, ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104218106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 RICHLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27596-9274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-654-1414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 RICHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27596-9274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-654-1414
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  1980 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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