Provider Demographics
NPI:1659588176
Name:SULLENBERGER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SULLENBERGER
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:PO BOX 63
Mailing Address - Street 2:418 GALLIMORE RD
Mailing Address - City:PORT WILLIAM
Mailing Address - State:OH
Mailing Address - Zip Code:45164-0063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1640 WEST REDSTONE CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-776-7235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20373225200000X
OHPTA 05746225200000X
TX2056595225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant