Provider Demographics
NPI:1053335661
Name:JESSE W WHITE
Entity type:Organization
Organization Name:JESSE W WHITE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/P.T.
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:330-821-2249
Mailing Address - Street 1:75 GLAMORGAN ST
Mailing Address - Street 2:STE 110
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2938
Mailing Address - Country:US
Mailing Address - Phone:330-821-2249
Mailing Address - Fax:330-821-9318
Practice Address - Street 1:75 GLAMORGAN ST
Practice Address - Street 2:STE 110
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2938
Practice Address - Country:US
Practice Address - Phone:330-821-2249
Practice Address - Fax:330-821-9318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-002099225100000X
OHPT-009178225100000X
OHPT-008153225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCL7471OtherR/R MEDICARE GROUP PROV #
OH2682968Medicaid
OH2682968Medicaid