Provider Demographics
NPI:1326395419
Name:SEABURG, JESSICA R (PT, DPT, OCS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:R
Last Name:SEABURG
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8268
Mailing Address - Country:US
Mailing Address - Phone:208-265-0610
Mailing Address - Fax:
Practice Address - Street 1:13 TUMBLEWEED TRL
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-8937
Practice Address - Country:US
Practice Address - Phone:406-224-8908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-4380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011002618OtherMEDICARE PTAN
MT7150064Medicaid