Provider Demographics
NPI:1801920590
Name:WATERS, JESSICA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WATERS
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 1:2555 ENGLISH BENCH RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52140-7542
Mailing Address - Country:US
Mailing Address - Phone:563-568-3060
Mailing Address - Fax:
Practice Address - Street 1:40 1ST ST SE
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172-2022
Practice Address - Country:US
Practice Address - Phone:563-568-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00758225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant