Provider Demographics
NPI:1629230933
Name:WEAGLE, JESSICA LEE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LEE
Last Name:WEAGLE
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 WEST BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-1407
Mailing Address - Country:US
Mailing Address - Phone:508-344-2886
Mailing Address - Fax:
Practice Address - Street 1:294 WEST BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1407
Practice Address - Country:US
Practice Address - Phone:508-344-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2641173C00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No173C00000XOther Service ProvidersReflexologist