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General NPI Number Information
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NPI Number | 1356192918
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Entity Type | Individual
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Provider Name | CONESHA MICHAEL MT
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Gender | Female
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Dates
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Enumeration Date | 04/01/2024
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Last Update Date | 04/01/2024
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Provider Practice Location Address
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Address Line | 262 IRIS AVE
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City | JACKSON
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State | MS
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Zip | 39206-3905
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Country | US
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Telephone | 769-798-6814
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 HIGHLAND COLONY PKWY STE 5203
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City | RIDGELAND
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State | MS
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Zip | 39157-2079
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Country | US
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Telephone | 769-798-6814
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 2917
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License Number State | MS
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