Provider Demographics
NPI:1134267412
Name:SHELL, JESSICA KRISTIN (CMT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:KRISTIN
Last Name:SHELL
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CLOVERLEAF SQ
Mailing Address - Street 2:BUILDING A-2
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-2758
Mailing Address - Country:US
Mailing Address - Phone:276-523-7128
Mailing Address - Fax:276-523-7213
Practice Address - Street 1:1 CLOVERLEAF SQ
Practice Address - Street 2:BUILDING A-2
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2758
Practice Address - Country:US
Practice Address - Phone:276-523-7128
Practice Address - Fax:276-523-7213
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist