Provider Demographics
NPI:1093157299
Name:POLITO, JESSICA SUZAN (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUZAN
Last Name:POLITO
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 1:4145 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50313-3525
Mailing Address - Country:US
Mailing Address - Phone:515-371-9678
Mailing Address - Fax:
Practice Address - Street 1:3682 68TH ST
Practice Address - Street 2:SUITE 9
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-3401
Practice Address - Country:US
Practice Address - Phone:515-371-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006341225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist