Provider Demographics
NPI:1679666838
Name:DAVIS-MIERZWA, JESSICA L (DC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:DAVIS-MIERZWA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14062-9803
Mailing Address - Country:US
Mailing Address - Phone:716-965-4343
Mailing Address - Fax:716-965-2667
Practice Address - Street 1:24 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14062
Practice Address - Country:US
Practice Address - Phone:716-877-0676
Practice Address - Fax:716-877-4248
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8812310OtherINDEPENDENT HEALTH
NY8812310OtherINDEPENDENT HEALTH
NYCC8079Medicare PIN