=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801100508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA CHERRON NEW PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2010
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2225 N 1000 W
-----------------------------------------------------
City | PARKER CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47368-9303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-625-1628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2225 N 1000 W
-----------------------------------------------------
City | PARKER CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47368-9303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-625-1628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 06003580A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------