Provider Demographics
NPI:1447419981
Name:SALLY, JESSE (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:SALLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 GAMMA DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2917
Mailing Address - Country:US
Mailing Address - Phone:412-963-6480
Mailing Address - Fax:412-963-6820
Practice Address - Street 1:107 GAMMA DR
Practice Address - Street 2:SUITE 220
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238-2917
Practice Address - Country:US
Practice Address - Phone:412-963-6480
Practice Address - Fax:412-963-6820
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0161732081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine