Provider Demographics
NPI:1881018257
Name:BALLESTEROS, JESSICA (MT, MMP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:MT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:624 N 8TH STREET
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-0363
Mailing Address - Country:US
Mailing Address - Phone:928-300-9090
Mailing Address - Fax:
Practice Address - Street 1:4297 E ZALESKY RD
Practice Address - Street 2:2665 VILLAGE DR
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-5639
Practice Address - Country:US
Practice Address - Phone:928-300-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-06075225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist