Provider Demographics
NPI:1154161461
Name:PETTIFORD, JALEN D
Entity type:Individual
Prefix:
First Name:JALEN
Middle Name:D
Last Name:PETTIFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 WALLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-8689
Mailing Address - Country:US
Mailing Address - Phone:919-717-7836
Mailing Address - Fax:
Practice Address - Street 1:5121 KINGDOM WAY STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6063
Practice Address - Country:US
Practice Address - Phone:800-442-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician