Provider Demographics
NPI:1780302414
Name:JESSIE, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:JESSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1252
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-1252
Mailing Address - Country:US
Mailing Address - Phone:504-518-3135
Mailing Address - Fax:
Practice Address - Street 1:2801 HUEY P LONG AVE APT 111
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-6956
Practice Address - Country:US
Practice Address - Phone:504-518-3135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA9224225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist