Provider Demographics
NPI:1770066060
Name:WILKINSON, JESSICA LEIGH (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:632 ERWIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-2407
Mailing Address - Country:US
Mailing Address - Phone:304-483-5261
Mailing Address - Fax:
Practice Address - Street 1:503 MEADOW DR
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1018
Practice Address - Country:US
Practice Address - Phone:254-826-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2124306225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant