Provider Demographics
NPI:1801045737
Name:CAVAZOS, JESSIE W (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:W
Last Name:CAVAZOS
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:S
Other - Last Name:WENZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, OCS
Mailing Address - Street 1:546 LOST CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-1631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 MOLLY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6503
Practice Address - Country:US
Practice Address - Phone:770-517-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24212225100000X
NY031754225100000X
GAPT011804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist