MEDICARE: TAMMISHA JORDAN MASSAGE THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	227022538	IL
2	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1124766084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMISHA JORDAN MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	1716 N LINDER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-4220
Country	:	US
Telephone Number	:	312-774-1144
Fax Number	:

Provider Business Practice Location Address
First Line	:	1716 N LINDER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-4220
Country	:	US
Telephone Number	:	312-774-1144
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2022
Last Update Date	:	05/21/2022

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