Provider Demographics
NPI:1568976058
Name:MEJIA, JESSIKA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSIKA
Middle Name:
Last Name:MEJIA
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 1:316 DOVE COTTAGE LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-0516
Mailing Address - Country:US
Mailing Address - Phone:972-841-1219
Mailing Address - Fax:
Practice Address - Street 1:1000 TANDAL PL
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-8842
Practice Address - Country:US
Practice Address - Phone:919-266-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6415225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant