Healthcare Provider Details

I. General information

NPI: 1225590029
Provider Name (Legal Business Name): JESSICA LYNN CANTRELL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 CANTON RD NW
CARROLLTON OH
44615-8440
US

IV. Provider business mailing address

559 CANTON RD NW
CARROLLTON OH
44615-8440
US

V. Phone/Fax

Practice location:
  • Phone: 330-627-7611
  • Fax: 330-627-6773
Mailing address:
  • Phone: 330-627-7611
  • Fax: 330-627-6773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.024412
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: