Provider Demographics
NPI:1801620281
Name:STOVALL, JESSICA NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:STOVALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:MOYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8840 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-7403
Mailing Address - Country:US
Mailing Address - Phone:504-266-3627
Mailing Address - Fax:
Practice Address - Street 1:8840 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-7403
Practice Address - Country:US
Practice Address - Phone:504-266-3627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
136297225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist