Provider Demographics
NPI:1336967967
Name:KINNISON, JESSICA SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SUE
Last Name:KINNISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUE
Other - Last Name:GRANDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:601 OH - 664N
Mailing Address - Street 2:PO BOX 966
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138
Mailing Address - Country:US
Mailing Address - Phone:740-380-8233
Mailing Address - Fax:740-385-7458
Practice Address - Street 1:601 OH - 664N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138
Practice Address - Country:US
Practice Address - Phone:740-380-8233
Practice Address - Fax:740-385-7458
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3978503Medicaid