Provider Demographics
NPI:1104375039
Name:ROOT, JESSICA (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ROOT
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 1:91 HOWARD AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3652
Mailing Address - Country:US
Mailing Address - Phone:937-604-7628
Mailing Address - Fax:614-212-4900
Practice Address - Street 1:300 POLARIS PKWY
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7989
Practice Address - Country:US
Practice Address - Phone:614-776-0970
Practice Address - Fax:614-212-4900
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT0177522251X0800X
IL070.022656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic