Provider Demographics
NPI:1275013880
Name:ELENBURG, JESSICA (BGE, DT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ELENBURG
Suffix:
Gender:F
Credentials:BGE, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 LINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4077
Mailing Address - Country:US
Mailing Address - Phone:870-520-8761
Mailing Address - Fax:
Practice Address - Street 1:148 LINWOOD DR
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4077
Practice Address - Country:US
Practice Address - Phone:870-520-8761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist