Provider Demographics
NPI:1649817958
Name:HADDAD, JESSICA FAYE-GOMEZ
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAYE-GOMEZ
Last Name:HADDAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-4419
Mailing Address - Country:US
Mailing Address - Phone:704-960-9254
Mailing Address - Fax:
Practice Address - Street 1:7022 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-6058
Practice Address - Country:US
Practice Address - Phone:704-960-9254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12596224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty