Provider Demographics
NPI:1992321590
Name:LANFORD, JESSICA MARIE (, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:LANFORD
Suffix:
Gender:F
Credentials:, DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:EBERHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 N BELAIR SQ STE 19
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4324
Mailing Address - Country:US
Mailing Address - Phone:706-831-1128
Mailing Address - Fax:770-230-0157
Practice Address - Street 1:601 N BELAIR SQ STE 19
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4324
Practice Address - Country:US
Practice Address - Phone:706-831-1128
Practice Address - Fax:770-230-0157
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10268225100000X
GAPT014616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist