Provider Demographics
NPI:1306593561
Name:MAIN, JESSIE LYNN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSIE LYNN
Middle Name:
Last Name:MAIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 SHORTWOODS RD
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812-3216
Mailing Address - Country:US
Mailing Address - Phone:203-496-6257
Mailing Address - Fax:
Practice Address - Street 1:92 SHORTWOODS RD
Practice Address - Street 2:
Practice Address - City:NEW FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06812-3216
Practice Address - Country:US
Practice Address - Phone:203-496-6257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046619225100000X
CT13470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist