Provider Demographics
NPI:1306163563
Name:MARSHALL, JESSICA RAE (LMT)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:RAE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 MARY CREST DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-6354
Mailing Address - Country:US
Mailing Address - Phone:502-417-4492
Mailing Address - Fax:
Practice Address - Street 1:3029 MARY CREST DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-6354
Practice Address - Country:US
Practice Address - Phone:502-417-4492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1285225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY-1285OtherKENTUCKY STATE MASSAGE THERAPY LICENSE ID