Provider Demographics
NPI:1679906994
Name:NGUYEN, JESSICA MOE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MOE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 THORNTON OAKS CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1553
Mailing Address - Country:US
Mailing Address - Phone:919-740-6753
Mailing Address - Fax:
Practice Address - Street 1:5100 SHARON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4768
Practice Address - Country:US
Practice Address - Phone:704-553-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-11
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5137225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant