Provider Demographics
NPI:1043585565
Name:FERRELL, JESSE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:FERRELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 W MONROE ST
Mailing Address - Street 2:# 1401
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-4553
Mailing Address - Country:US
Mailing Address - Phone:602-573-1309
Mailing Address - Fax:
Practice Address - Street 1:4700 N CENTRAL AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1719
Practice Address - Country:US
Practice Address - Phone:602-573-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-04127P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMTY-04127POtherMASSAGE THERAPY LICENSE