Provider Demographics
NPI:1790834257
Name:CRANNELL, JESSICA M (MPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:CRANNELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-2217
Mailing Address - Country:US
Mailing Address - Phone:315-717-0020
Mailing Address - Fax:
Practice Address - Street 1:402 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2217
Practice Address - Country:US
Practice Address - Phone:315-717-0020
Practice Address - Fax:315-717-0024
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11492114OtherCAQH
NY02673898Medicaid
NY11492114OtherCAQH