Healthcare Provider Details

I. General information

NPI: 1184008880
Provider Name (Legal Business Name): SAMANTHA NOEL JAGGERS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LAGRANGE RD
NEW CASTLE KY
40050-6743
US

IV. Provider business mailing address

525 LAGRANGE RD
NEW CASTLE KY
40050-6743
US

V. Phone/Fax

Practice location:
  • Phone: 502-321-5197
  • Fax:
Mailing address:
  • Phone: 502-321-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberBMTMTH00220860
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: