Provider Demographics
NPI:1770190308
Name:LA RUSCH, JESIKA RIAN (LMT)
Entity Type:Individual
Prefix:
First Name:JESIKA
Middle Name:RIAN
Last Name:LA RUSCH
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 1:1801 MCCORD WAY APT 1246
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-1200
Mailing Address - Country:US
Mailing Address - Phone:682-300-1565
Mailing Address - Fax:
Practice Address - Street 1:1801 MCCORD WAY APT 1246
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-1200
Practice Address - Country:US
Practice Address - Phone:682-300-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT105628225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist