MEDICARE: JESSICA BUNDERSON

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	12807-146	WI

General Provider Information

NPI Number	:	1598163917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BUNDERSON

Provider Business Mailing Address
First Line	:	3348 N SILVER LAKE DR
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-4768
Country	:	US
Telephone Number	:	262-434-0418
Fax Number	:

Provider Business Practice Location Address
First Line	:	3348 N SILVER LAKE DR
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-4768
Country	:	US
Telephone Number	:	262-434-0418
Fax Number	:

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

Provider Enumeration Date	:	12/17/2014
Last Update Date	:	12/17/2014

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