Provider Demographics
NPI:1598444051
Name:GILLISPIE, JESSICA ROSE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:GILLISPIE
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 1:4660 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-5716
Mailing Address - Country:US
Mailing Address - Phone:440-670-3060
Mailing Address - Fax:
Practice Address - Street 1:33200 HEALTH CAMPUS BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1481
Practice Address - Country:US
Practice Address - Phone:440-670-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA006180225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty