Provider Demographics
NPI:1073145470
Name:WACKER, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WACKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:135 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 E EMERALD AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-5550
Practice Address - Country:US
Practice Address - Phone:865-524-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5147208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation