Healthcare Provider Details

I. General information

NPI: 1295137883
Provider Name (Legal Business Name): JESSICA KOWALLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 N MILWAUKEE ST STE B
BOISE ID
83704-7107
US

IV. Provider business mailing address

1740 N MILWAUKEE ST STE B
BOISE ID
83704-7107
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-9500
  • Fax: 208-377-8449
Mailing address:
  • Phone: 208-377-9500
  • Fax: 208-377-8449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-2110
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: