Provider Demographics
NPI:1669561700
Name:DWORSHAK, JAN MARIE (CMT)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:MARIE
Last Name:DWORSHAK
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 8TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4036
Mailing Address - Country:US
Mailing Address - Phone:320-253-5967
Mailing Address - Fax:
Practice Address - Street 1:1804 TROTT AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-2743
Practice Address - Country:US
Practice Address - Phone:320-222-2639
Practice Address - Fax:320-222-1494
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist