Provider Demographics
NPI:1124739420
Name:EYANSON, JESSICA M (LMT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:EYANSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:WOGERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 W MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:CRIDERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45806-2382
Mailing Address - Country:US
Mailing Address - Phone:567-204-9683
Mailing Address - Fax:
Practice Address - Street 1:200 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CRIDERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45806-2382
Practice Address - Country:US
Practice Address - Phone:567-204-9683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025579225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist