Provider Demographics
NPI:1013382217
Name:LIVENGOOD, JESSICA ELIZABETH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:LIVENGOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:ELIZABETH
Other - Last Name:SHAMBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:29 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-6419
Mailing Address - Country:US
Mailing Address - Phone:937-207-5540
Mailing Address - Fax:
Practice Address - Street 1:187 W SCHROCK RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2890
Practice Address - Country:US
Practice Address - Phone:614-355-7500
Practice Address - Fax:614-355-7533
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1367225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid