Basic Information
Provider Information
NPI: 1003140872
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KING
FirstName: JENNA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2000 NEUSE BLVD
Address2:  
City: NEW BERN
State: NC
PostalCode: 285603449
CountryCode: US
TelephoneNumber: 2526338640
FaxNumber:  
Practice Location
Address1: 2000 NEUSE BLVD
Address2:  
City: NEW BERN
State: NC
PostalCode: 285603449
CountryCode: US
TelephoneNumber: 2526338640
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/28/2009
LastUpdateDate: 09/28/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X12191NCY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
018TE01NCBLUE CROSSOTHER


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