Provider Demographics
NPI:1245081546
Name:PURDOM, JEASSALYNNE (LMT, LE)
Entity type:Individual
Prefix:
First Name:JEASSALYNNE
Middle Name:
Last Name:PURDOM
Suffix:
Gender:F
Credentials:LMT, LE
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:PURDOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT, LE
Mailing Address - Street 1:6806 KENOSHA PASS UNIT B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1802
Mailing Address - Country:US
Mailing Address - Phone:325-262-2988
Mailing Address - Fax:
Practice Address - Street 1:802 LYDIA ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-2623
Practice Address - Country:US
Practice Address - Phone:512-829-8738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX131846225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist