Provider Demographics
NPI:1215094180
Name:YAGER, JESSICA BLYSTONE (PT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BLYSTONE
Last Name:YAGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-2114
Mailing Address - Fax:252-338-2115
Practice Address - Street 1:101 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-2114
Practice Address - Fax:252-338-2115
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211953Medicaid
NC079XWOtherBCBS
NC250227Medicare PIN
NC079XWOtherBCBS
NC271572BMedicare PIN