Provider Demographics
NPI:1902021439
Name:GAUTHIER, JESSICA (PTA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1715
Mailing Address - Country:US
Mailing Address - Phone:508-791-8740
Mailing Address - Fax:
Practice Address - Street 1:173 GROVE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1715
Practice Address - Country:US
Practice Address - Phone:508-791-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7811225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant