Provider Demographics
NPI:1023246618
Name:JENNINGS, LACY D (PT)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:D
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:D
Other - Last Name:BOGOSLAWSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1108 DRESSER CT
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7328
Mailing Address - Country:US
Mailing Address - Phone:919-876-8302
Mailing Address - Fax:919-954-8706
Practice Address - Street 1:1108 DRESSER CT
Practice Address - Street 2:SUITE 201B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7328
Practice Address - Country:US
Practice Address - Phone:919-876-8302
Practice Address - Fax:919-954-8706
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist