Healthcare Provider Details

I. General information

NPI: 1497159339
Provider Name (Legal Business Name): JILL JEGLUM LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3804 SE JEFFERSON ST
STUART FL
34997-5435
US

IV. Provider business mailing address

3804 SE JEFFERSON ST
STUART FL
34997-5435
US

V. Phone/Fax

Practice location:
  • Phone: 520-474-1883
  • Fax:
Mailing address:
  • Phone: 520-474-1883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA28503
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: