Provider Demographics
NPI:1962121731
Name:MYRICK, JESSIE (LAC, DIPL OM)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:MYRICK
Suffix:
Gender:F
Credentials:LAC, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3984 SENECA RD
Mailing Address - Street 2:
Mailing Address - City:HECTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14841-9604
Mailing Address - Country:US
Mailing Address - Phone:520-445-5524
Mailing Address - Fax:
Practice Address - Street 1:407 TAUGHANNOCK BLVD STE E
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3252
Practice Address - Country:US
Practice Address - Phone:520-445-5524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5574171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist