Provider Demographics
NPI:1447094693
Name:GYURO, JESSICA RAE (LMT, CMT, SMT)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:RAE
Last Name:GYURO
Suffix:
Gender:F
Credentials:LMT, CMT, SMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 HILLCREST ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4119
Mailing Address - Country:US
Mailing Address - Phone:262-339-8130
Mailing Address - Fax:
Practice Address - Street 1:713 HILLCREST ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-4119
Practice Address - Country:US
Practice Address - Phone:262-339-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-22
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17548-146225700000X
IL227.023535225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist