MEDICARE: JESSICA KOWALLIS

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	MASG-2110	ID

General Provider Information

NPI Number	:	1295137883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KOWALLIS

Provider Business Mailing Address
First Line	:	1740 N MILWAUKEE ST STE B
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-7107
Country	:	US
Telephone Number	:	208-377-9500
Fax Number	:	208-377-8449

Provider Business Practice Location Address
First Line	:	1740 N MILWAUKEE ST STE B
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-7107
Country	:	US
Telephone Number	:	208-377-9500
Fax Number	:	208-377-8449

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

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	09/25/2014

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