Provider Demographics
NPI:1831670819
Name:VINYARD, JESSICA LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:VINYARD
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 1:1086 EAGLE NEST DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1267
Mailing Address - Country:US
Mailing Address - Phone:314-520-0037
Mailing Address - Fax:
Practice Address - Street 1:783 WEBER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3318
Practice Address - Country:US
Practice Address - Phone:573-756-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant