Basic Information
| Provider Information | |||||||||
| NPI: | 1043330020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | SHAFFER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3627 SPRING FIELD RD | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278048356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524432766 | ||||||||
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| Practice Location | |||||||||
| Address1: | 143 NASHVILLE COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278561284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524595565 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2007 | ||||||||
| LastUpdateDate: | 12/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2603 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7201148 | 05 | NC | MEDICAID | 75289 | 01 | BCBS | OTHER |