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General NPI Number Information
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NPI Number | 1215333901
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Entity Type | Organization
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Legal Business Name | SELF
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Dates
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Enumeration Date | 11/07/2014
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Last Update Date | 11/07/2014
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Provider Practice Location Address
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Address Line | 410 JASON DR
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City | RICHMOND
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State | KY
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Zip | 40475-2291
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Country | US
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Telephone | 270-775-2790
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Fax |
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Provider Business Mailing Address
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Address Line | 410 JASON DR
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City | RICHMOND
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State | KY
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Zip | 40475-2291
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Country | US
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Telephone | 270-775-2790
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MS. JESSICA RENEE BICKWERMERT
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Credential | DPT
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Telephone | 270-775-2790
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 006497
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License Number State | KY
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