Basic Information
| Provider Information | |||||||||
| NPI: | 1326515727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | JENEVIEVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 MILLS AVE UNIT 227 | ||||||||
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| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094203810 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3919 SOUTH CAROLINA 14 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642529941 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.