Healthcare Provider Details

I. General information

NPI: 1417864935
Provider Name (Legal Business Name): J'S 42ND TREND HAIR RESTORATION STU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8408 SIX FORKS RD
RALEIGH NC
27615-3076
US

IV. Provider business mailing address

1110 CANNONBALL RUN APT 206
KNIGHTDALE NC
27545-6655
US

V. Phone/Fax

Practice location:
  • Phone: 301-633-0510
  • Fax:
Mailing address:
  • Phone: 301-633-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MR. AMOS JORDAN JR. JR.
Title or Position: CRANIAL PROSTHESIS MEDICAL WIG/ HAI
Credential:
Phone: 301-633-0510