Healthcare Provider Details

I. General information

NPI: 1619884020
Provider Name (Legal Business Name): JENNIFER LANE HATLEY LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

9112 DEERSHIRE CT
RALEIGH NC
27615-4099
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-2082
  • Fax:
Mailing address:
  • Phone: 919-345-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2684
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: