Provider Demographics
NPI:1992978787
Name:NATIVIDAD, JESSICA GRACE DOMINGO (PT)
Entity type:Individual
Prefix:MISS
First Name:JESSICA GRACE
Middle Name:DOMINGO
Last Name:NATIVIDAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3290 N RIDGE RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3655
Mailing Address - Country:US
Mailing Address - Phone:410-750-9006
Mailing Address - Fax:410-750-0787
Practice Address - Street 1:3290 N RIDGE RD
Practice Address - Street 2:SUITE 290
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3655
Practice Address - Country:US
Practice Address - Phone:410-750-9006
Practice Address - Fax:410-750-0787
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist