Healthcare Provider Details

I. General information

NPI: 1629608005
Provider Name (Legal Business Name): JESSICA SPENCER PT, DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CLINTON PKWY STE 200
LAWRENCE KS
66047-2145
US

IV. Provider business mailing address

3500 CLINTON PKWY STE 200
LAWRENCE KS
66047-2145
US

V. Phone/Fax

Practice location:
  • Phone: 785-505-3780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-05873
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01089
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: