Provider Demographics
NPI:1639721285
Name:RIESGO, JESSICA (MA, LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RIESGO
Suffix:
Gender:F
Credentials:MA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 E FORT LOWELL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1625
Mailing Address - Country:US
Mailing Address - Phone:520-240-2034
Mailing Address - Fax:
Practice Address - Street 1:3208 E FORT LOWELL RD STE 102
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-1625
Practice Address - Country:US
Practice Address - Phone:520-240-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AZMT-08984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty