Provider Demographics
NPI:1568735751
Name:MCDANIEL, JESSICA WARD
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:WARD
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 SUSSEX AVE
Mailing Address - Street 2:CHARLOTTE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-6255
Mailing Address - Country:US
Mailing Address - Phone:843-450-7699
Mailing Address - Fax:
Practice Address - Street 1:1918 WILMORE WALK DR
Practice Address - Street 2:CHARLOTTE
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4531
Practice Address - Country:US
Practice Address - Phone:843-450-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2736225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant