Provider Demographics
NPI:1326363482
Name:SHARP, JESSICA NICHOLE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICHOLE
Last Name:SHARP
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 1:42568 FOY CEMETARY
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454
Mailing Address - Country:US
Mailing Address - Phone:985-981-6012
Mailing Address - Fax:
Practice Address - Street 1:42568 FOY CEMETERY RD
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-5800
Practice Address - Country:US
Practice Address - Phone:985-981-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4429225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist