=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104687441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ROSALES LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2024
-----------------------------------------------------
Last Update Date | 01/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 N POWER RD STE 2
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-8436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-689-7426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1846 E INNOVATION PARK DR STE 100
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-689-7426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT-29415
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------