Healthcare Provider Details

I. General information

NPI: 1720451800
Provider Name (Legal Business Name): JESSICA A. ISOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 S ALABAMA ST
INDIANAPOLIS IN
46225-3301
US

IV. Provider business mailing address

426 S ALABAMA ST
INDIANAPOLIS IN
46225-3301
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-2489
  • Fax: 317-528-3771
Mailing address:
  • Phone: 317-528-2489
  • Fax: 317-528-3771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05011190A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: