Provider Demographics
NPI:1700648078
Name:BUNKER, JESICA L (LMT)
Entity Type:Individual
Prefix:MS
First Name:JESICA
Middle Name:L
Last Name:BUNKER
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 1:6301 M 68 HWY STE D
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-9366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6301 M 68 HWY STE D
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-9366
Practice Address - Country:US
Practice Address - Phone:231-268-1477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011067225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty