Provider Demographics
NPI:1013169465
Name:VASS, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VASS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 PRINCESS PL
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-6647
Mailing Address - Country:US
Mailing Address - Phone:903-952-7104
Mailing Address - Fax:
Practice Address - Street 1:3505 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8510
Practice Address - Country:US
Practice Address - Phone:903-561-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2055770225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant