Provider Demographics
NPI:1225645286
Name:JIMISON, LAURA LEEANNE (LMBT/LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEEANNE
Last Name:JIMISON
Suffix:
Gender:F
Credentials:LMBT/LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 TIFFANY BLVD APT E
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1830
Mailing Address - Country:US
Mailing Address - Phone:719-696-2726
Mailing Address - Fax:
Practice Address - Street 1:746 TIFFANY BLVD APT E
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1830
Practice Address - Country:US
Practice Address - Phone:719-696-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0022119225700000X
NC673481225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist