Healthcare Provider Details

I. General information

NPI: 1376155135
Provider Name (Legal Business Name): JESSICA PRINCE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 LOGANVILLE HWY STE 1130
BETHLEHEM GA
30620-2153
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
BIRMINGHAM AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 770-867-7463
  • Fax: 770-307-0383
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT014800
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: