Healthcare Provider Details

I. General information

NPI: 1265070734
Provider Name (Legal Business Name): JESSICA JANE FUNCHEON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E CARMEL DR STE 154
CARMEL IN
46032-3054
US

IV. Provider business mailing address

16368 ANDERSON WAY
NOBLESVILLE IN
46062-5521
US

V. Phone/Fax

Practice location:
  • Phone: 317-342-3800
  • Fax:
Mailing address:
  • Phone: 317-201-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: