=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639659972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA D MATHIS PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2018
-----------------------------------------------------
Last Update Date | 08/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 N COLLEGE AVE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-713-8630
-----------------------------------------------------
Fax | 479-713-5150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1125 N COLLEGE AVE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-713-8630
-----------------------------------------------------
Fax | 479-713-5150
-----------------------------------------------------
=====================================================
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 | 4425
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------