Healthcare Provider Details

I. General information

NPI: 1144315490
Provider Name (Legal Business Name): JESSE JON TROUTMAN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14247 N 26TH LN
PHOENIX AZ
85023-5952
US

IV. Provider business mailing address

14247 N 26TH LN
PHOENIX AZ
85023-5952
US

V. Phone/Fax

Practice location:
  • Phone: 602-228-4644
  • Fax:
Mailing address:
  • Phone: 602-228-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-02975P
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: