Healthcare Provider Details

I. General information

NPI: 1639668809
Provider Name (Legal Business Name): JESSICA LYNN COUNTRYMAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COLLEGE ST
SOMERSET KY
42501-1307
US

IV. Provider business mailing address

PO BOX 1659
SOMERSET KY
42502-1659
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-2636
  • Fax: 606-677-0412
Mailing address:
  • Phone: 606-677-2636
  • Fax: 606-677-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA01847
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: