Healthcare Provider Details

I. General information

NPI: 1043628969
Provider Name (Legal Business Name): JENNIFER RASCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 FORRESTGATE DR
WINSTON SALEM NC
27103-2930
US

IV. Provider business mailing address

930 3RD ST
GREENSBORO NC
27405-6967
US

V. Phone/Fax

Practice location:
  • Phone: 336-930-9600
  • Fax: 336-930-9930
Mailing address:
  • Phone: 336-890-3200
  • Fax: 336-890-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5007020
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: