Basic Information
| Provider Information | |||||||||
| NPI: | 1215179536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONWAY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 633448 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452633448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138534749 | ||||||||
| FaxNumber: | 5138534740 | ||||||||
| Practice Location | |||||||||
| Address1: | 6909 GOOD SAMARITAN DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452475208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132455434 | ||||||||
| FaxNumber: | 5132455424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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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 | 35535 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05008928A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT.013643 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0074629 | 05 | OH | MEDICAID |