Provider Demographics
NPI:1336543024
Name:HARRIS, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1624 CORINTHIAN DR
Mailing Address - Street 2:APT 1815
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-8879
Mailing Address - Country:US
Mailing Address - Phone:808-382-1079
Mailing Address - Fax:
Practice Address - Street 1:1624 CORINTHIAN DR
Practice Address - Street 2:APT 1815
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-8879
Practice Address - Country:US
Practice Address - Phone:808-382-1079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPTA03150225200000X
OHPTA07179225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant