Healthcare Provider Details

I. General information

NPI: 1588641021
Provider Name (Legal Business Name): JESSICA MCCLELLAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 SNOW RD
BROOKPARK OH
44142-2859
US

IV. Provider business mailing address

23825 COMMERCE PARK SUITE B
BEACHWOOD OH
44122-5837
US

V. Phone/Fax

Practice location:
  • Phone: 216-265-3454
  • Fax: 216-267-5553
Mailing address:
  • Phone: 216-292-6363
  • Fax: 216-292-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT11272
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: