Provider Demographics
NPI:1588076541
Name:WADE, JESSICA FOXWORTH (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FOXWORTH
Last Name:WADE
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 1:1146 ELMA G. MILES PARKWAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313
Mailing Address - Country:US
Mailing Address - Phone:912-368-9355
Mailing Address - Fax:912-368-9360
Practice Address - Street 1:1146 ELMA G. MILES PARKWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-368-9355
Practice Address - Fax:912-368-9360
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist