Provider Demographics
NPI:1497099139
Name:HAWK, JESSICA (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HAWK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:13026-0179
Mailing Address - Country:US
Mailing Address - Phone:315-730-1153
Mailing Address - Fax:
Practice Address - Street 1:371 MAIN ST.
Practice Address - Street 2:2ND FLOOR
Practice Address - City:AURORA
Practice Address - State:NY
Practice Address - Zip Code:13026
Practice Address - Country:US
Practice Address - Phone:315-710-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 004835171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist