Provider Demographics
NPI:1982190476
Name:BATES, JESSICA LYNNE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:BATES
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-1093
Mailing Address - Country:US
Mailing Address - Phone:636-221-2879
Mailing Address - Fax:
Practice Address - Street 1:42202 FM 1774 RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-4204
Practice Address - Country:US
Practice Address - Phone:281-252-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-08
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT60132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer