Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | ||
N | 2251N0400X | Physical Therapist - Neurology |
NPI | 1225643208 |
---|---|
Provider Name | Jessica Evans |
First Address | Grand Rapids, MI 49534-4641 |
Second Address | Grand Rapids, MI 49503-5247 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2020 |
Last Update Date | 15/09/2020 |