Healthcare Provider Details

I. General information

NPI: 1831523265
Provider Name (Legal Business Name): JESSICA WALLACE SAVILLE DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LYNNE WALLACE DPT, PT

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 09/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 LOGANVILLE HWY STE 1130
BETHLEHEM GA
30620-2144
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 404-671-9525
  • Fax: 404-671-9526
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 NumberPT011171
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: