Provider Demographics
NPI:1013106392
Name:HOGAN, JESSYCA M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JESSYCA
Middle Name:M
Last Name:HOGAN
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 1:1 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3853
Mailing Address - Country:US
Mailing Address - Phone:386-677-5909
Mailing Address - Fax:386-677-5909
Practice Address - Street 1:1 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-3853
Practice Address - Country:US
Practice Address - Phone:386-677-5909
Practice Address - Fax:386-677-5909
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA51691225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist