Provider Demographics
NPI:1659647139
Name:TYSON, JESSICA JEANIE
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:JEANIE
Last Name:TYSON
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 1:17 MASER AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-7246
Mailing Address - Country:US
Mailing Address - Phone:304-312-5120
Mailing Address - Fax:
Practice Address - Street 1:316 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6243
Practice Address - Country:US
Practice Address - Phone:304-243-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist