Provider Demographics
NPI:1962986893
Name:EDDINS, JESSICA (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:EDDINS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 LAKE HOLDING ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6860
Mailing Address - Country:US
Mailing Address - Phone:919-607-7290
Mailing Address - Fax:
Practice Address - Street 1:4801 EDWARDS MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4417
Practice Address - Country:US
Practice Address - Phone:919-787-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA4024225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant