MEDICARE: JOVAN PLUNKETT LMT

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	227.020475	IL

General Provider Information

NPI Number	:	1184265589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOVAN PLUNKETT LMT

Provider Business Mailing Address
First Line	:	710 BRADLEY AVE
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-1605
Country	:	US
Telephone Number	:	708-573-2963
Fax Number	:

Provider Business Practice Location Address
First Line	:	4019 183RD ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-5306
Country	:	US
Telephone Number	:	708-573-2963
Fax Number	:

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

Provider Enumeration Date	:	10/07/2019
Last Update Date	:	10/07/2019

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