Provider Demographics
NPI:1689799967
Name:DOHERTY, JESSICA RENEE (MPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RENEE
Other - Last Name:GLADU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:33 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-1466
Mailing Address - Country:US
Mailing Address - Phone:617-733-8233
Mailing Address - Fax:
Practice Address - Street 1:33 HIGH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-1466
Practice Address - Country:US
Practice Address - Phone:617-733-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2014-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist