Provider Demographics
NPI:1962418525
Name:MADDOCKS, JENNIFER M (MSPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:MADDOCKS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MICHAUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3701 NW CARY PARKWAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513
Mailing Address - Country:US
Mailing Address - Phone:919-388-0111
Mailing Address - Fax:919-388-8668
Practice Address - Street 1:3701 NW CARY PARKWAY
Practice Address - Street 2:SUITE 301
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513
Practice Address - Country:US
Practice Address - Phone:919-388-0111
Practice Address - Fax:919-388-8668
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3210671OtherAETNA HMO
NC6698131OtherGHI
NC836264OtherUHC ACN MPN
NC5004734OtherAETNA PPO
NC7360555OtherUHC ACN MPN
NC079C2OtherBCBS
NC2502481Medicare ID - Type Unspecified