Provider Demographics
NPI:1225590029
Name:CANTRELL, JESSICA LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CANTRELL
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 1:559 CANTON RD NW
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-8440
Mailing Address - Country:US
Mailing Address - Phone:330-627-7611
Mailing Address - Fax:330-627-6773
Practice Address - Street 1:559 CANTON RD NW
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-8440
Practice Address - Country:US
Practice Address - Phone:330-627-7611
Practice Address - Fax:330-627-6773
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.024412225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty