Provider Demographics
NPI:1174068407
Name:FUENTES, JACQUELINE ANN (LAT,ATC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:FUENTES
Suffix:
Gender:F
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1562
Mailing Address - Country:US
Mailing Address - Phone:336-765-5664
Mailing Address - Fax:336-768-6713
Practice Address - Street 1:120 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1562
Practice Address - Country:US
Practice Address - Phone:336-765-5664
Practice Address - Fax:336-768-6713
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer