Basic Information
| Provider Information | |||||||||
| NPI: | 1982893855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALSLEY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT, OCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WORRELL | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 36TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173660 | ||||||||
| FaxNumber: | 3049173674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 GRAND CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042957290 | ||||||||
| FaxNumber: | 3042955922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 11/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT002657 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT016087 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00609422 | 01 | RAILROAD MEDICARE | OTHER | 3810011111 | 05 | WV | MEDICAID | 2826240 | 05 | OH | MEDICAID |