Provider Demographics
NPI:1114431657
Name:CARTER, JESSICA LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CARTER
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 1:1745 HAMILTON RD STE 355
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1954
Mailing Address - Country:US
Mailing Address - Phone:517-708-0017
Mailing Address - Fax:
Practice Address - Street 1:1745 HAMILTON RD STE 355
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1954
Practice Address - Country:US
Practice Address - Phone:517-708-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist