Provider Demographics
NPI:1184226052
Name:BREAUX, JESSICA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BREAUX
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 1:516 E LODGE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3740
Mailing Address - Country:US
Mailing Address - Phone:480-650-1493
Mailing Address - Fax:
Practice Address - Street 1:516 E LODGE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3740
Practice Address - Country:US
Practice Address - Phone:480-650-1493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26164225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist