Provider Demographics
NPI:1205541356
Name:KEOWN, JESSICA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KEOWN
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 1:28001 SCHOENHERR RD STE 628001
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-4396
Mailing Address - Country:US
Mailing Address - Phone:586-999-8330
Mailing Address - Fax:
Practice Address - Street 1:28001 SCHOENHERR RD STE 628001
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-4396
Practice Address - Country:US
Practice Address - Phone:586-999-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55020081462251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic