=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609699701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DAVIS LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 392 W APPLE ST STE 3
-----------------------------------------------------
City | RINGTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17967-9448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-212-9191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 393 LOCUST LN
-----------------------------------------------------
City | CATAWISSA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17820-8246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-212-9191
-----------------------------------------------------
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 | MSG015396
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------