Basic Information
| Provider Information | |||||||||
| NPI: | 1811277098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELGIORNO | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 N MAIN ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645285700 | ||||||||
| FaxNumber: | 8645285701 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR | ||||||||
| Address2: | STE C250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540952 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6436 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.