Provider Demographics
NPI:1023765096
Name:DALUSUNG, JESSICA LEIGH
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:DALUSUNG
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 1:4700 HWY 80 E STE L
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-2942
Mailing Address - Country:US
Mailing Address - Phone:912-643-9999
Mailing Address - Fax:
Practice Address - Street 1:4700 HWY 80 E STE L
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-2942
Practice Address - Country:US
Practice Address - Phone:912-643-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014779225700000X
VA0019011091225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty