Provider Demographics
NPI:1205369063
Name:SHRADER, JESSICA RUBY
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RUBY
Last Name:SHRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:RUBY
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15201 SHADY GROVE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3217
Mailing Address - Country:US
Mailing Address - Phone:019-484-3953
Mailing Address - Fax:301-407-1860
Practice Address - Street 1:15201 SHADY GROVE RD STE 106
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3217
Practice Address - Country:US
Practice Address - Phone:301-948-4295
Practice Address - Fax:301-407-1860
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8560225100000X
MD29158225100000X
NC16506225100000X
HI4829225100000X
TX1284626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist