Provider Demographics
NPI:1841460524
Name:COULLARD, JESSICA (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COULLARD
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:PO BOX 35643
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99803-5643
Mailing Address - Country:US
Mailing Address - Phone:907-209-0866
Mailing Address - Fax:
Practice Address - Street 1:11806 GLACIER HWY STE 1B
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8644
Practice Address - Country:US
Practice Address - Phone:907-020-9086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK149089225700000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator