Healthcare Provider Details

I. General information

NPI: 1104375039
Provider Name (Legal Business Name): JESSICA ROOT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 POLARIS PKWY
WESTERVILLE OH
43082-7989
US

IV. Provider business mailing address

91 HOWARD AVE UNIT 1
WORTHINGTON OH
43085-3652
US

V. Phone/Fax

Practice location:
  • Phone: 614-776-0970
  • Fax: 614-212-4900
Mailing address:
  • Phone: 937-604-7628
  • Fax: 614-212-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.022656
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT017752
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: