Provider Demographics
NPI:1598763948
Name:WHITE, JESSE WILLIAM (PT)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:WILLIAM
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:JESSE
Other - Middle Name:WILLIAM
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AT
Mailing Address - Street 1:75 GLAMORGAN ST
Mailing Address - Street 2:STE. 110
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2938
Mailing Address - Country:US
Mailing Address - Phone:330-821-2249
Mailing Address - Fax:330-821-9318
Practice Address - Street 1:75 GLAMORGAN ST
Practice Address - Street 2:STE. 110
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2938
Practice Address - Country:US
Practice Address - Phone:330-821-2249
Practice Address - Fax:330-821-9318
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-002099225100000X
OHAT-0004392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0450355Medicaid
OH791650025OtherR/R MEDICARE PROV #
OH791650025OtherR/R MEDICARE PROV #
OH0450355Medicaid