Healthcare Provider Details

I. General information

NPI: 1437112679
Provider Name (Legal Business Name): JENNIFER RACKLEY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 S HAWTHORNE RD DBA EDWIN H. MARTINAT REHABILITATION CENTER
WINSTON SALEM NC
27103-3916
US

IV. Provider business mailing address

2000 FRONTIS PLAZA BLVD STE 200 (ATTN) FORSYTH MEDICAL GROUP
WINSTON SALEM NC
27103-5616
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-6700
  • Fax:
Mailing address:
  • Phone: 336-277-2435
  • Fax: 336-277-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8518
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: