Provider Demographics
NPI:1821488636
Name:LEE, JESSICA ANNA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNA
Last Name:LEE
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 1:1707 NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-4158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 AIRPORT RD
Practice Address - Street 2:SUITE E
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4030
Practice Address - Country:US
Practice Address - Phone:850-896-1870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-01
Last Update Date:2015-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA76802225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist