Provider Demographics
NPI:1578943106
Name:CZECHOWICZ, JESSICA SHANE (BCTMB)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHANE
Last Name:CZECHOWICZ
Suffix:
Gender:F
Credentials:BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11757 E LORETTA CIR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-9363
Mailing Address - Country:US
Mailing Address - Phone:907-982-5572
Mailing Address - Fax:
Practice Address - Street 1:1901 N HEMMER RD
Practice Address - Street 2:#213
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9690
Practice Address - Country:US
Practice Address - Phone:907-982-5572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist