Provider Demographics
NPI:1063071561
Name:PETTY, JESSICA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:PETTY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 HARNESS RD
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-5402
Mailing Address - Country:US
Mailing Address - Phone:636-524-2322
Mailing Address - Fax:
Practice Address - Street 1:12826 DAYLIGHT CIR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1890
Practice Address - Country:US
Practice Address - Phone:314-328-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016037457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant