=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417864935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J'S 42ND TREND HAIR RESTORATION STU
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2026
-----------------------------------------------------
Last Update Date | 08/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8408 SIX FORKS RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-3076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-633-0510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 CANNONBALL RUN APT 206
-----------------------------------------------------
City | KNIGHTDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27545-6655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-633-0510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRANIAL PROSTHESIS MEDICAL WIG/ HAI
-----------------------------------------------------
Name | MR. AMOS JORDAN JR. JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-633-0510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------