MEDICARE: JESSICA BAKER PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2457	SC

General Provider Information

NPI Number	:	1376904177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BAKER PTA

Provider Business Mailing Address
First Line	:	3681 LEAPHART RD STE A
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3068
Country	:	US
Telephone Number	:	803-454-6090
Fax Number	:	803-454-6090

Provider Business Practice Location Address
First Line	:	3681 LEAPHART RD STE A
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3068
Country	:	US
Telephone Number	:	803-454-6090
Fax Number	:	803-454-6090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2016
Last Update Date	:	03/08/2016

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