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General NPI Number Information
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NPI Number | 1376088435
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Entity Type | Organization
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Legal Business Name | JAE LLC
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 512 NORTHHAMPTON STREET
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City | EDWARDSVILLE
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State | PA
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Zip | 18704
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Country | US
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Telephone | 570-212-9520
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Fax |
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Provider Business Mailing Address
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Address Line | 827 STOCKTON MOUNTAIN RD
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City | BEAVER MEADOWS
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State | PA
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Zip | 18216-6505
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Country | US
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Telephone | 570-299-9246
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Fax |
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Authorized Official
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Title or Position | DOULA/LICENSED MASSAGE THERAPIST
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Name | MS. JESSICA ANN ENRIQUEZ
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Credential | LMT
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Telephone | 570-299-9247
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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 | MSG006829
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 374J00000X
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Taxonomy Name | Doula
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License Number |
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License Number State |
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