Provider Demographics
NPI:1063512168
Name:MILLS, JESSICA (DPT)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9835 NORTHCROSS CENTER CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7302
Mailing Address - Country:US
Mailing Address - Phone:704-896-8688
Mailing Address - Fax:
Practice Address - Street 1:9835 NORTHCROSS CENTER CT
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7302
Practice Address - Country:US
Practice Address - Phone:704-896-8688
Practice Address - Fax:704-896-7975
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10752174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212138Medicaid