Basic Information
Provider Information | |||||||||
NPI: | 1528288396 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILUK | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | POTEET | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | POTEET | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | LYNETTE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OCS, FAAOMPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 CRESCENT CENTRE DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | TN | ||||||||
PostalCode: | 370677285 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153731350 | ||||||||
FaxNumber: | 6152219054 | ||||||||
Practice Location | |||||||||
Address1: | 1300 DACY LN STE 100 | ||||||||
Address2: |   | ||||||||
City: | KYLE | ||||||||
State: | TX | ||||||||
PostalCode: | 786404194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5122138001 | ||||||||
FaxNumber: | 5124360874 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2007 | ||||||||
LastUpdateDate: | 03/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1151172 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.