Basic Information
| Provider Information | |||||||||
| NPI: | 1013382217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVENGOOD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAMBAUGH | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033016419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372075540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 187 W SCHROCK RD | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430812890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143557500 | ||||||||
| FaxNumber: | 6143557533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2015 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1367 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |