Provider Demographics
NPI:1073878864
Name:ADAMCZAK, JESSICA HUMBACH (DPT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:HUMBACH
Last Name:ADAMCZAK
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:HUMBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC
Mailing Address - Street 1:3113 CRESCENT KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-2457
Mailing Address - Country:US
Mailing Address - Phone:847-899-8037
Mailing Address - Fax:
Practice Address - Street 1:8918 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6691
Practice Address - Country:US
Practice Address - Phone:704-900-8960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP137242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ40350AOtherMEDICARE PTAN