Provider Demographics
NPI:1306338629
Name:PAULY, JESSICA ANN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:PAULY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:EBENKAMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3400 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-7541
Mailing Address - Country:US
Mailing Address - Phone:620-545-5248
Mailing Address - Fax:
Practice Address - Street 1:19931 W KELLOGG DR UNIT A
Practice Address - Street 2:
Practice Address - City:GODDARD
Practice Address - State:KS
Practice Address - Zip Code:67052-8864
Practice Address - Country:US
Practice Address - Phone:316-550-6132
Practice Address - Fax:316-550-6215
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-05885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist