Basic Information
| Provider Information | |||||||||
| NPI: | 1952831166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESSE | ||||||||
| FirstName: | KARA | ||||||||
| MiddleName: | HEATH | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HEATH | ||||||||
| OtherFirstName: | KARA | ||||||||
| OtherMiddleName: | FLORENCE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DAVID GRANT MEDICAL CENTER | ||||||||
| Address2: | 101 BODIN CIR | ||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233040 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | DAVID GRANT MEDICAL CENTER | ||||||||
| Address2: | 101 BODIN CIR | ||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233304 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2017017380 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2017027518 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.