Healthcare Provider Details

I. General information

NPI: 1376088435
Provider Name (Legal Business Name): JAE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 NORTHHAMPTON STREET
EDWARDSVILLE PA
18704
US

IV. Provider business mailing address

827 STOCKTON MOUNTAIN RD
BEAVER MEADOWS PA
18216-6505
US

V. Phone/Fax

Practice location:
  • Phone: 570-212-9520
  • Fax:
Mailing address:
  • Phone: 570-299-9246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMSG006829
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA ANN ENRIQUEZ
Title or Position: DOULA/LICENSED MASSAGE THERAPIST
Credential: LMT
Phone: 570-299-9247