Basic Information
| Provider Information | |||||||||
| NPI: | 1801045737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVAZOS | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | DPT, OCS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WENZEL | ||||||||
| OtherFirstName: | JESSIE | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | DPT, OCS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 546 LOST CREEK DR | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301881631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 655 MOLLY LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301896503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705171080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 11/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 24212 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 031754 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT011804 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.