Provider Demographics
NPI:1205596210
Name:WATERWORTH, JESSICA ANN (DC)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:WATERWORTH
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:N3641 STATE ROAD 146
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:53932-9512
Mailing Address - Country:US
Mailing Address - Phone:608-513-7876
Mailing Address - Fax:
Practice Address - Street 1:1434 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4035
Practice Address - Country:US
Practice Address - Phone:920-261-5607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5709-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor