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General NPI Number Information
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NPI Number | 1891836946
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Entity Type | Individual
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Provider Name | JESSICA MARIE FODGE L.M.T.
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Gender | Female
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Dates
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Enumeration Date | 02/10/2007
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Last Update Date | 12/22/2024
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Provider Practice Location Address
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Address Line | 233 2ND AVE S
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City | OKANOGAN
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State | WA
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Zip | 98840-9703
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Country | US
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Telephone | 509-429-0096
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1604
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City | OKANOGAN
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State | WA
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Zip | 98840-1604
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Country | US
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Telephone | 509-331-6308
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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 | MA00011423
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License Number State | WA
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