Provider Demographics
NPI:1740440379
Name:SULLIVAN, JESSICA L (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SULLIVAN
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:3015 LIMITED LN NW
Practice Address - Street 2:STE B
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-2638
Practice Address - Country:US
Practice Address - Phone:360-709-0700
Practice Address - Fax:360-709-0703
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60590036225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist