Provider Demographics
NPI:1386025427
Name:CONRAD, JESSICA (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:SHIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4251 LAHMEYER RD.
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:1913 NORTH WAYNE ST,
Practice Address - Street 2:SUITE D
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703
Practice Address - Country:US
Practice Address - Phone:260-624-2288
Practice Address - Fax:260-624-2286
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011737A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist