Provider Demographics
NPI:1891836946
Name:FODGE, JESSICA MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:FODGE
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 1:1315 E SCOOTNEY ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1921
Mailing Address - Country:US
Mailing Address - Phone:509-331-6308
Mailing Address - Fax:
Practice Address - Street 1:752 S SUNSET ACRES RD
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-9545
Practice Address - Country:US
Practice Address - Phone:509-989-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011423225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist