Healthcare Provider Details

I. General information

NPI: 1174077176
Provider Name (Legal Business Name): JESSICA SIMEONE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14700 BALTIMORE AVE #106
LAUREL MD
20707-4877
US

IV. Provider business mailing address

10705 CARDINGTON WAY APT T2
COCKEYSVILLE MD
21030-3065
US

V. Phone/Fax

Practice location:
  • Phone: 240-754-2203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA0000846
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: