Provider Demographics
NPI:1508439332
Name:JEDLICK, MICHELLE DESIRAE (CMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DESIRAE
Last Name:JEDLICK
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DESIRAE
Other - Last Name:LA CHAPELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2850 W LINCOLN AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-6219
Mailing Address - Country:US
Mailing Address - Phone:714-770-9104
Mailing Address - Fax:
Practice Address - Street 1:2850 W LINCOLN AVE APT B
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-6219
Practice Address - Country:US
Practice Address - Phone:714-770-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85940225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist