Provider Demographics
NPI:1649572900
Name:MCLEOD, JESSICA L (PT, DPT, AT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:PT, DPT, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1581
Mailing Address - Country:US
Mailing Address - Phone:616-897-7055
Mailing Address - Fax:616-897-7366
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1581
Practice Address - Country:US
Practice Address - Phone:616-897-7055
Practice Address - Fax:616-897-7366
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015420225100000X
MI26010004402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer