Provider Demographics
NPI:1275620510
Name:MOLLEUR, JESSICA LAUREN (LICAC, DNBAO)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LAUREN
Last Name:MOLLEUR
Suffix:
Gender:F
Credentials:LICAC, DNBAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 BEACON ST
Mailing Address - Street 2:2F
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-1341
Mailing Address - Country:US
Mailing Address - Phone:617-733-5729
Mailing Address - Fax:
Practice Address - Street 1:211 BEACON ST
Practice Address - Street 2:2F
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-1341
Practice Address - Country:US
Practice Address - Phone:617-733-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226091171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist