Provider Demographics
NPI:1548556319
Name:BOZARTH, JESSICA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOZARTH
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 1:3 MADISON ST
Mailing Address - Street 2:APT ONE HALF
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2619
Mailing Address - Country:US
Mailing Address - Phone:847-648-0165
Mailing Address - Fax:
Practice Address - Street 1:765 ELA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2385
Practice Address - Country:US
Practice Address - Phone:847-550-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.012854225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist