Provider Demographics
NPI:1326513185
Name:WHITEHEAD, JESSICA LAWANDA (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAWANDA
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:PT
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 2121
Mailing Address - Street 2:
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-2121
Mailing Address - Country:US
Mailing Address - Phone:606-672-6683
Mailing Address - Fax:
Practice Address - Street 1:21937 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749
Practice Address - Country:US
Practice Address - Phone:606-672-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004980225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist