Provider Demographics
NPI:1437400900
Name:SHAUGHNESSY-MALLOY, JESSICA M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:SHAUGHNESSY-MALLOY
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 1:101 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5303
Mailing Address - Country:US
Mailing Address - Phone:863-412-9197
Mailing Address - Fax:
Practice Address - Street 1:101 S 10TH ST
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5303
Practice Address - Country:US
Practice Address - Phone:863-412-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist