Provider Demographics
NPI:1215418769
Name:BREEDEN, JESSICA ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:BREEDEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5206 SULFUR SPRING DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5799
Mailing Address - Country:US
Mailing Address - Phone:912-321-9715
Mailing Address - Fax:
Practice Address - Street 1:2505 S 37TH ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7103
Practice Address - Country:US
Practice Address - Phone:254-298-7300
Practice Address - Fax:254-742-0000
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2094411225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant