Healthcare Provider Details

I. General information

NPI: 1366566754
Provider Name (Legal Business Name): JOSEPH EDWARD JARRELL JR. LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JOSEPH JARRELL JR.

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5402 MACCORKLE AVE SE BODY TRANQUIL LLC
CHARLESTON WV
25304-2224
US

IV. Provider business mailing address

5402 MACCORKLE AVE SE BODY TRANQUIL LLC
CHARLESTON WV
25304-2224
US

V. Phone/Fax

Practice location:
  • Phone: 304-395-3865
  • Fax:
Mailing address:
  • Phone: 304-395-3865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number20062167
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: