Provider Demographics
NPI:1255116034
Name:GORE, JESSICA (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GORE
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 1:1154 MORSE AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94089-4621
Mailing Address - Country:US
Mailing Address - Phone:408-839-3397
Mailing Address - Fax:
Practice Address - Street 1:1003 RIVER ST STE C
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1754
Practice Address - Country:US
Practice Address - Phone:831-457-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52795225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant