Provider Demographics
NPI:1376622886
Name:KING, JESSICA L (RPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E FULTON ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5455
Mailing Address - Country:US
Mailing Address - Phone:620-275-8400
Mailing Address - Fax:620-275-2687
Practice Address - Street 1:101 E FULTON ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5455
Practice Address - Country:US
Practice Address - Phone:620-275-8400
Practice Address - Fax:620-275-2687
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS115652OtherBCBS #
KS115652Medicare ID - Type UnspecifiedMEDICARE #