MEDICARE: JACQUELYN FANNO CMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	25356	CA

General Provider Information

NPI Number	:	1811646433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN FANNO CMT

Provider Business Mailing Address
First Line	:	18630 BURBANK BLVD APT 209
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-2660
Country	:	US
Telephone Number	:	239-404-9742
Fax Number	:

Provider Business Practice Location Address
First Line	:	18630 BURBANK BLVD APT 209
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-2660
Country	:	US
Telephone Number	:	818-514-5728
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2022
Last Update Date	:	03/21/2022

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Directions to “ JACQUELYN FANNO CMT” Practice Location

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