Healthcare Provider Details

I. General information

NPI: 1043860976
Provider Name (Legal Business Name): JESSICA S ALEXANDER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 KENMOOR AVE SE STE H
GRAND RAPIDS MI
49546-2391
US

IV. Provider business mailing address

300 MADISON AVE SE # 3
GRAND RAPIDS MI
49503-4618
US

V. Phone/Fax

Practice location:
  • Phone: 616-466-4175
  • Fax:
Mailing address:
  • Phone: 503-453-4622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501011087
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: