Provider Demographics
NPI:1922572197
Name:FONNER, JESSICA ANN (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:FONNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 HILLCREST AVE SW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2809
Mailing Address - Country:US
Mailing Address - Phone:330-904-8697
Mailing Address - Fax:
Practice Address - Street 1:3927 38TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2900
Practice Address - Country:US
Practice Address - Phone:330-493-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT8103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist