Provider Demographics
NPI:1558661348
Name:LYNCH, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6687 SKIPPER RD APT 1227
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3051 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8536
Practice Address - Country:US
Practice Address - Phone:478-971-2235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002679225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant