Provider Demographics
NPI:1952600314
Name:ELLEBRUCH, JESSICA RAE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:ELLEBRUCH
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ALLEGHENY CTR APT 212
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-5230
Mailing Address - Country:US
Mailing Address - Phone:330-858-2411
Mailing Address - Fax:
Practice Address - Street 1:121 CRANBERRY RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4629
Practice Address - Country:US
Practice Address - Phone:724-458-9473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist