Healthcare Provider Details

I. General information

NPI: 1174363055
Provider Name (Legal Business Name): JESSI B SHANE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 SW 811TH RD
CENTERVIEW MO
64019-9291
US

IV. Provider business mailing address

386 SW 811TH RD
CENTERVIEW MO
64019-9291
US

V. Phone/Fax

Practice location:
  • Phone: 409-719-8036
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2024003807
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: