Provider Demographics
NPI:1225282668
Name:O'GORMAN, JESSICA DREW (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DREW
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-4001
Mailing Address - Country:US
Mailing Address - Phone:781-593-2727
Mailing Address - Fax:781-593-2542
Practice Address - Street 1:103 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4001
Practice Address - Country:US
Practice Address - Phone:781-593-2727
Practice Address - Fax:781-593-2542
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7260 PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist