Provider Demographics
NPI:1669027405
Name:MONTGOMERY, JESSICA LUANNE (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LUANNE
Last Name:MONTGOMERY
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 1:494 LCR 240
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-2094
Mailing Address - Country:US
Mailing Address - Phone:254-300-2460
Mailing Address - Fax:
Practice Address - Street 1:831 TEHUACANA HWY
Practice Address - Street 2:
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667
Practice Address - Country:US
Practice Address - Phone:254-562-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2071787225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant