Basic Information
| Provider Information | |||||||||
| NPI: | 1922682426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 GRAND CENTRAL AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046932781 | ||||||||
| FaxNumber: | 3046932171 | ||||||||
| Practice Location | |||||||||
| Address1: | 2434 RICHMILLER LN UNIT B | ||||||||
| Address2: | |||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457141075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404231500 | ||||||||
| FaxNumber: | 7404231504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2021 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.