Provider Demographics
NPI:1306695002
Name:JESSEE, JENNIFER C (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:JESSEE
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-3533
Mailing Address - Country:US
Mailing Address - Phone:865-696-1543
Mailing Address - Fax:
Practice Address - Street 1:4881 COUGAR TRAIL RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3930
Practice Address - Country:US
Practice Address - Phone:540-674-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260024222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer