Provider Demographics
NPI:1811462658
Name:EASTRIDGE, JESSICA LEIAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEIAN
Last Name:EASTRIDGE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIAN
Other - Last Name:EWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:632 KANAWHA BLVD W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-1922
Mailing Address - Country:US
Mailing Address - Phone:304-539-2919
Mailing Address - Fax:
Practice Address - Street 1:300 BAKER LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2900
Practice Address - Country:US
Practice Address - Phone:304-346-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist