Provider Demographics
NPI:1962789859
Name:MILLWARD, JACQUELINE KENNEDY (MHS, LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:KENNEDY
Last Name:MILLWARD
Suffix:
Gender:F
Credentials:MHS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1991 FORDHAM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3774
Mailing Address - Country:US
Mailing Address - Phone:910-484-3114
Mailing Address - Fax:910-484-8824
Practice Address - Street 1:1991 FORDHAM DR STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3774
Practice Address - Country:US
Practice Address - Phone:910-484-3114
Practice Address - Fax:910-484-8824
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer