Provider Demographics
NPI:1154936003
Name:HAMILTON, JACK BRADLEY
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:BRADLEY
Last Name:HAMILTON
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 1:408 NORTHEAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2434
Mailing Address - Country:US
Mailing Address - Phone:910-592-2343
Mailing Address - Fax:
Practice Address - Street 1:408 NORTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2434
Practice Address - Country:US
Practice Address - Phone:910-592-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFT2031225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty