Basic Information
| Provider Information | |||||||||
| NPI: | 1851367403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCANN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAMBERT | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2145 COUNTRY CLUB RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285462404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109395759 | ||||||||
| FaxNumber: | 9109394951 | ||||||||
| Practice Location | |||||||||
| Address1: | 2145 COUNTRY CLUB RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285462404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109395759 | ||||||||
| FaxNumber: | 9109394951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 025205-1 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P16408 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02585399 | 05 | NY | MEDICAID |