Provider Demographics
NPI:1922454081
Name:DOYLE, JESSICA BOUGHTON (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BOUGHTON
Last Name:DOYLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JODY
Other - Last Name:BOUGHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:174 SPRING GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-8722
Mailing Address - Country:US
Mailing Address - Phone:518-569-9489
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PLACE
Practice Address - Street 2:SUITE 175
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234
Practice Address - Country:US
Practice Address - Phone:214-442-4246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist