Provider Demographics
NPI:1669982278
Name:TOLLIVER, JESSICA G (LMT, MMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:LMT, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21009 EDDIE RD
Mailing Address - Street 2:
Mailing Address - City:HENSLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72065-8065
Mailing Address - Country:US
Mailing Address - Phone:501-650-9014
Mailing Address - Fax:
Practice Address - Street 1:400 W CAPITOL AVE STE 2848
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-3415
Practice Address - Country:US
Practice Address - Phone:501-650-9014
Practice Address - Fax:501-712-3075
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8115225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR8115OtherSTATE LICENSE