MEDICARE: JESSICA CONRAD DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	05011737A	IN

General Provider Information

NPI Number	:	1386025427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA CONRAD DPT

Provider Business Mailing Address
First Line	:	4251 LAHMEYER RD.
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815
Country	:	US
Telephone Number	:	260-432-4700
Fax Number	:	260-459-9262

Provider Business Practice Location Address
First Line	:	1913 NORTH WAYNE ST,
Second Line	:	SUITE D
City	:	ANGOLA
State	:	IN
Zip	:	46703
Country	:	US
Telephone Number	:	260-624-2288
Fax Number	:	260-624-2286

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	10/27/2017

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