MEDICARE: JESSICA LYNN GREEN 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	MA80897	FL

General Provider Information

NPI Number	:	1417630385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LYNN GREEN LMT

Provider Business Mailing Address
First Line	:	3925 SW COUNTY ROAD 240
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32024-4921
Country	:	US
Telephone Number	:	386-853-1559
Fax Number	:

Provider Business Practice Location Address
First Line	:	3925 SW COUNTY ROAD 240
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32024-4921
Country	:	US
Telephone Number	:	386-853-1559
Fax Number	:

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

Provider Enumeration Date	:	08/08/2023
Last Update Date	:	08/21/2023

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