Provider Demographics
NPI:1003274226
Name:BROGAN, JESSICA NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:BROGAN
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 1:523 MAPLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:OH
Mailing Address - Zip Code:45153-9718
Mailing Address - Country:US
Mailing Address - Phone:513-703-7883
Mailing Address - Fax:
Practice Address - Street 1:60 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4812
Practice Address - Country:US
Practice Address - Phone:513-703-7883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0062532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer