MEDICARE: MS. JESSICA B WADDELL LMBT

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	13274	NC

General Provider Information

NPI Number	:	1881394310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA B WADDELL LMBT

Provider Business Mailing Address
First Line	:	4955 AMITY LN
Second Line	:
City	:	IRON STATION
State	:	NC
Zip	:	28080-9755
Country	:	US
Telephone Number	:	803-207-9902
Fax Number	:

Provider Business Practice Location Address
First Line	:	4955 AMITY LN
Second Line	:
City	:	IRON STATION
State	:	NC
Zip	:	28080-9755
Country	:	US
Telephone Number	:	803-207-9902
Fax Number	:

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

Provider Enumeration Date	:	03/03/2023
Last Update Date	:	03/03/2023

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