Provider Demographics
NPI:1952653321
Name:LAUDER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAUDER
Suffix:
Gender:F
Credentials:
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 2214
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-2214
Mailing Address - Country:US
Mailing Address - Phone:603-731-3527
Mailing Address - Fax:
Practice Address - Street 1:24 PLEASANT ST.
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818
Practice Address - Country:US
Practice Address - Phone:603-731-3527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3097M172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist