=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629742218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA JOBBER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2021
-----------------------------------------------------
Last Update Date | 08/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 231 TREETOP DR STE 301
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28311-0606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-491-8217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 OCEAN BLVD W
-----------------------------------------------------
City | HOLDEN BEACH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28462-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | P20619
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------