Provider Demographics
NPI:1639924277
Name:MIZZELL, JESSIE (PT/DPT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:MIZZELL
Suffix:
Gender:F
Credentials:PT/DPT
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:FUNCHESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3374 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-8248
Mailing Address - Country:US
Mailing Address - Phone:803-245-0808
Mailing Address - Fax:803-245-0974
Practice Address - Street 1:119 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2407
Practice Address - Country:US
Practice Address - Phone:803-937-5605
Practice Address - Fax:803-937-6256
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist