Basic Information
| Provider Information | |||||||||
| NPI: | 1093838328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTZELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOSTYU | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3701 NW CARY PARKWAY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 NW CARY PARKWAY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6836 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1108G | 01 | NC | BCBS | OTHER |