Provider Demographics
NPI:1467166801
Name:DWYER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DWYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24098 SAFFRON RD APT B
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-8707
Mailing Address - Country:US
Mailing Address - Phone:573-855-1779
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE HL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1257
Practice Address - Country:US
Practice Address - Phone:573-855-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer