Provider Demographics
NPI:1093047706
Name:DYGERT, JENNIFER L (MT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DYGERT
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W GENESEE STREET RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-9435
Mailing Address - Country:US
Mailing Address - Phone:315-252-5789
Mailing Address - Fax:
Practice Address - Street 1:2115 W GENESEE STREET RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-9435
Practice Address - Country:US
Practice Address - Phone:315-252-5789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008538-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist