Provider Demographics
NPI:1477857126
Name:HODGMAN, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:HODGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 NE 119TH ST
Mailing Address - Street 2:
Mailing Address - City:BISCAYNE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6233
Mailing Address - Country:US
Mailing Address - Phone:254-449-5065
Mailing Address - Fax:
Practice Address - Street 1:521 NE 119TH ST
Practice Address - Street 2:
Practice Address - City:BISCAYNE PARK
Practice Address - State:FL
Practice Address - Zip Code:33161-6233
Practice Address - Country:US
Practice Address - Phone:254-449-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT110422225700000X
FLMA65795225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist