Provider Demographics
NPI:1073312997
Name:SHANE, JESSICA LYNN
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:SHANE
Suffix:
Gender:
Credentials:
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:ROCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 PIONEER VILLAS
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-5968
Mailing Address - Country:US
Mailing Address - Phone:724-570-2941
Mailing Address - Fax:
Practice Address - Street 1:11 PIONEER VILLAS
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-5968
Practice Address - Country:US
Practice Address - Phone:724-570-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer