Provider Demographics
NPI:1215179536
Name:CONWAY, JESSICA LEE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:CONWAY
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:PO BOX 633448
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3448
Mailing Address - Country:US
Mailing Address - Phone:513-853-4749
Mailing Address - Fax:513-853-4740
Practice Address - Street 1:6909 GOOD SAMARITAN DR
Practice Address - Street 2:SUITE A
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-5208
Practice Address - Country:US
Practice Address - Phone:513-245-5434
Practice Address - Fax:513-245-5424
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35535225100000X
IN05008928A225100000X
OHPT.013643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074629Medicaid
OHH103220Medicare PIN
OH0225920002Medicare NSC