Provider Demographics
NPI:1538779814
Name:CLARK, JESSICA TAYLOR (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TAYLOR
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:TAYLOR
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:800 PEACHTREE ST NE STE E2
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1245
Practice Address - Country:US
Practice Address - Phone:404-254-3319
Practice Address - Fax:404-600-6092
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist