Provider Demographics
NPI:1194077925
Name:DONOVAN, JESSICA ANN (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3044 KETTERING BLVD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3044 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1922
Practice Address - Country:US
Practice Address - Phone:614-227-6952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.013465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist