Provider Demographics
NPI:1467765834
Name:REALE, JESSICA POWLEY (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:POWLEY
Last Name:REALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:N
Other - Last Name:POWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1505 JOHNSON FERRY RD STE 175
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-9109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 JOHNSON FERRY RD STE 175
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-9109
Practice Address - Country:US
Practice Address - Phone:770-415-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist