Provider Demographics
NPI:1710461835
Name:PECKHAM, JESSICA NICOLE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:NICOLE
Last Name:PECKHAM
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 1:33 WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-2227
Mailing Address - Country:US
Mailing Address - Phone:757-897-2261
Mailing Address - Fax:
Practice Address - Street 1:33 WINSTON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2227
Practice Address - Country:US
Practice Address - Phone:757-897-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605001225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant