MEDICARE: JENNIFER MARIE MERRILL 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	017324-1	NY

General Provider Information

NPI Number	:	1598295297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MARIE MERRILL MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	573 MIDDLE ROAD
Second Line	:
City	:	BAYPORT
State	:	NY
Zip	:	11705-1806
Country	:	US
Telephone Number	:	631-868-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	573 MIDDLE RD
Second Line	:
City	:	BAYPORT
State	:	NY
Zip	:	11705-1916
Country	:	US
Telephone Number	:	631-868-3232
Fax Number	:

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

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/21/2017

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