Provider Demographics
NPI:1659895985
Name:GILLEN, JESSICA LANIER (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LANIER
Last Name:GILLEN
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 1:214 LANEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NC
Mailing Address - Zip Code:28398-8719
Mailing Address - Country:US
Mailing Address - Phone:910-293-3144
Mailing Address - Fax:
Practice Address - Street 1:214 LANE FIELD RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NC
Practice Address - Zip Code:28398
Practice Address - Country:US
Practice Address - Phone:910-293-3144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA4448225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant