Provider Demographics
NPI:1770709032
Name:WYSOCARSKI, JESSICA D (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:WYSOCARSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 ARASH CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7328
Mailing Address - Country:US
Mailing Address - Phone:386-562-2650
Mailing Address - Fax:
Practice Address - Street 1:305 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8181
Practice Address - Country:US
Practice Address - Phone:386-676-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist