Provider Demographics
NPI:1962732529
Name:STEWART, JESSICA (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STEWART
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 1:403 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-6049
Mailing Address - Country:US
Mailing Address - Phone:573-759-2135
Mailing Address - Fax:
Practice Address - Street 1:403 E 10TH ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-6049
Practice Address - Country:US
Practice Address - Phone:573-759-2135
Practice Address - Fax:573-759-4487
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005226225100000X
MO2010011162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist