Provider Demographics
NPI:1720620123
Name:BASKERVILLE, JESSICA (PT, DPT, ATP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BASKERVILLE
Suffix:
Gender:F
Credentials:PT, DPT, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SPRING LAKE CV
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9239
Mailing Address - Country:US
Mailing Address - Phone:662-202-4468
Mailing Address - Fax:
Practice Address - Street 1:140 BURKE CALHOUN CITY RD
Practice Address - Street 2:
Practice Address - City:CALHOUN CITY
Practice Address - State:MS
Practice Address - Zip Code:38916-9690
Practice Address - Country:US
Practice Address - Phone:662-234-8559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist