Provider Demographics
NPI:1114472388
Name:BIVINS, JESSICA MASHAUN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MASHAUN
Last Name:BIVINS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 MEADOWOOD LN
Mailing Address - Street 2:0916
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8807
Mailing Address - Country:US
Mailing Address - Phone:321-276-2353
Mailing Address - Fax:
Practice Address - Street 1:9390 THE LANDING DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7180
Practice Address - Country:US
Practice Address - Phone:770-850-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012558225100000X
FLPT30539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist