Provider Demographics
NPI:1235795519
Name:GAWORECKI, JESSICA (LCAT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GAWORECKI
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8528 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9649
Mailing Address - Country:US
Mailing Address - Phone:315-720-3296
Mailing Address - Fax:
Practice Address - Street 1:8219 MARKET PL
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-9821
Practice Address - Country:US
Practice Address - Phone:315-720-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R-DMT-2359225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist