Provider Demographics
NPI:1639668809
Name:COUNTRYMAN, JESSICA LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:COUNTRYMAN
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:PO BOX 1659
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42502-1659
Mailing Address - Country:US
Mailing Address - Phone:606-677-2636
Mailing Address - Fax:606-677-0412
Practice Address - Street 1:105 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-1307
Practice Address - Country:US
Practice Address - Phone:606-677-2636
Practice Address - Fax:606-677-0412
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01847225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant