Provider Demographics
NPI:1639625312
Name:GARDNER, JESSY W (MS, OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:W
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MS, OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3547 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:CENTER VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18034-9713
Mailing Address - Country:US
Mailing Address - Phone:215-779-7809
Mailing Address - Fax:
Practice Address - Street 1:3547 HAWTHORNE DR
Practice Address - Street 2:
Practice Address - City:CENTER VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18034-9713
Practice Address - Country:US
Practice Address - Phone:215-779-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011044225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand