Basic Information
| Provider Information | |||||||||
| NPI: | 1821131467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUSHALL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7206 PLEASANT CT | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198021771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027621361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1812 MARSH RD | ||||||||
| Address2: | STORE 505 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198104581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024757500 | ||||||||
| FaxNumber: | 3024755787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| 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 | 2255A2300X | J3-0000167 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.