Provider Demographics
NPI:1639676372
Name:MOODY, JESSICA LEE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:MOODY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMBT
Mailing Address - Street 1:1885 MISS ELLIS LOOP NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7359
Mailing Address - Country:US
Mailing Address - Phone:704-806-7757
Mailing Address - Fax:704-806-7757
Practice Address - Street 1:19068 JENSEN WAY NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370
Practice Address - Country:US
Practice Address - Phone:360-271-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60807312225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist