Healthcare Provider Details

I. General information

NPI: 1184204646
Provider Name (Legal Business Name): JESSICA CARLSON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA KELLY PT, DPT

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W ELLIOT RD STE 109
TEMPE AZ
85284-1310
US

IV. Provider business mailing address

1037 E DIANA AVE
PHOENIX AZ
85020-3223
US

V. Phone/Fax

Practice location:
  • Phone: 480-374-4341
  • Fax:
Mailing address:
  • Phone: 805-458-4267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number31700
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: