Provider Demographics
NPI:1851401665
Name:LLACH, JESSICA R (RPT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:R
Last Name:LLACH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:RUSSELL
Other - Last Name:HEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:1800 WESTWIND DR
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-3055
Mailing Address - Country:US
Mailing Address - Phone:661-328-9913
Mailing Address - Fax:661-663-3095
Practice Address - Street 1:1800 WESTWIND DR
Practice Address - Street 2:SUITE 403
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-3055
Practice Address - Country:US
Practice Address - Phone:661-328-9913
Practice Address - Fax:661-663-3095
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00291508OtherRAILROAD MEDICARE
CAOPT185460Medicare ID - Type Unspecified
P26055Medicare UPIN