Provider Demographics
NPI:1942617691
Name:SHANKS, JESSICA (ATC, VATL)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:ATC, VATL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4269 NORMANDY CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-3909
Mailing Address - Country:US
Mailing Address - Phone:703-906-5103
Mailing Address - Fax:
Practice Address - Street 1:15721 FOREST PARK DR
Practice Address - Street 2:FOREST PARK HIGH SCHOOL
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-3180
Practice Address - Country:US
Practice Address - Phone:703-583-3200
Practice Address - Fax:703-583-6867
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260002012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer