Healthcare Provider Details

I. General information

NPI: 1679906788
Provider Name (Legal Business Name): JESSICA STEVENS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STIBNITE AVE UNIT 1
MCCALL ID
83638-4407
US

IV. Provider business mailing address

PO BOX 336
DONNELLY ID
83615-0336
US

V. Phone/Fax

Practice location:
  • Phone: 727-543-2506
  • Fax:
Mailing address:
  • Phone: 727-543-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS-3067
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: