Provider Demographics
NPI:1750118519
Name:KALLISH, JESSICA SARA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SARA
Last Name:KALLISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 SAINT DEVON XING
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8067
Mailing Address - Country:US
Mailing Address - Phone:770-286-8642
Mailing Address - Fax:
Practice Address - Street 1:9390 THE LANDING DR # 201
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7180
Practice Address - Country:US
Practice Address - Phone:770-852-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist