Provider Demographics
NPI:1326689795
Name:SPRAGUE, JESSE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SPRAGUE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 110TH AVE N # Q305
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-2258
Mailing Address - Country:US
Mailing Address - Phone:813-843-2374
Mailing Address - Fax:
Practice Address - Street 1:2561 HARN BLVD UNIT 6
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-5133
Practice Address - Country:US
Practice Address - Phone:813-843-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM88643225700000X
FLMA88643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist