Provider Demographics
NPI:1366752032
Name:CHILDERS, JESSICA LYNN (PT)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYNN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6529
Mailing Address - Country:US
Mailing Address - Phone:423-926-4331
Mailing Address - Fax:
Practice Address - Street 1:3 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 10
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6529
Practice Address - Country:US
Practice Address - Phone:423-926-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist