Provider Demographics
NPI:1912406349
Name:HUMPHREY, JESSICA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 WESTGATE CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8396
Mailing Address - Country:US
Mailing Address - Phone:844-266-4622
Mailing Address - Fax:
Practice Address - Street 1:220 W LOCKWOOD AVE STE 103
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2353
Practice Address - Country:US
Practice Address - Phone:314-962-6015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist