Healthcare Provider Details

I. General information

NPI: 1962511139
Provider Name (Legal Business Name): JESSICA DAWN EVANS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA DAWN DANCY

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E MAIN ST STE 310H2
WYTHEVILLE VA
24382-3300
US

IV. Provider business mailing address

800 E MAIN ST STE 310H2
WYTHEVILLE VA
24382-3300
US

V. Phone/Fax

Practice location:
  • Phone: 276-228-6200
  • Fax: 276-228-9175
Mailing address:
  • Phone: 276-228-6200
  • Fax: 276-228-9175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305203426
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: