Provider Demographics
NPI:1376396457
Name:MONROE, JESSICA VAUGHN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:VAUGHN
Last Name:MONROE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAPHNEE
Other - Middle Name:JESSICA
Other - Last Name:SOMMELIER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2 S PATTERSON PARK AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2103
Mailing Address - Country:US
Mailing Address - Phone:667-210-6622
Mailing Address - Fax:
Practice Address - Street 1:2 S PATTERSON PARK AVE STE 1A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-2103
Practice Address - Country:US
Practice Address - Phone:667-210-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDL20614327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist