Provider Demographics
NPI:1366621609
Name:PEREA, JESSICA MCKINNEY (LMT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MCKINNEY
Last Name:PEREA
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 1:4761 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-9507
Mailing Address - Country:US
Mailing Address - Phone:269-471-5324
Mailing Address - Fax:
Practice Address - Street 1:4761 GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-9507
Practice Address - Country:US
Practice Address - Phone:269-471-5324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT102704225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist