Provider Demographics
NPI:1306294392
Name:CAMPBELL, JESSICA (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W SUNFLOWER CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1365
Mailing Address - Country:US
Mailing Address - Phone:907-841-8658
Mailing Address - Fax:
Practice Address - Street 1:1701 N SEWARD MERIDIAN PKWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6682
Practice Address - Country:US
Practice Address - Phone:907-357-7463
Practice Address - Fax:907-376-5270
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101411225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist