Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 19625 | MA |
Y | 225100000X | Physical Therapist | PT023496 | PA |
NPI | 1003196932 |
---|---|
Provider Name | Laura Louise Jestes |
First Address | Grove City, PA 16127-2313 |
Second Address | Grove City, PA 16127-1544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2011 |
Last Update Date | 04/09/2014 |