Provider Demographics
NPI:1649925637
Name:LAGRAVINESE, JACLYN (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:LAGRAVINESE
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16025 S 50TH ST APT 1017
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-5002
Mailing Address - Country:US
Mailing Address - Phone:480-510-5352
Mailing Address - Fax:
Practice Address - Street 1:16025 S 50TH ST APT 1017
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-5002
Practice Address - Country:US
Practice Address - Phone:480-510-5352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17459225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist