Provider Demographics
NPI:1508929316
Name:BASHA, JESSICA (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BASHA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3600 W RAY RD
Mailing Address - Street 2:#2082
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-1372
Mailing Address - Country:US
Mailing Address - Phone:402-321-0406
Mailing Address - Fax:
Practice Address - Street 1:3403 E MAIN ST # 208
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-8683
Practice Address - Country:US
Practice Address - Phone:480-848-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ69442251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ961632Medicaid