Provider Demographics
NPI:1255725750
Name:NOVACK, JESSICA ANNE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:NOVACK
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 1:875 N WOODBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-2784
Mailing Address - Country:US
Mailing Address - Phone:260-341-3706
Mailing Address - Fax:
Practice Address - Street 1:875 N WOODBRIDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-2784
Practice Address - Country:US
Practice Address - Phone:260-341-3706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002171A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer