Provider Demographics
NPI:1619169133
Name:VIRTUE, JESSICA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:VIRTUE
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 1:12815 HWY 98 W
Mailing Address - Street 2:SUITE 114
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550
Mailing Address - Country:US
Mailing Address - Phone:850-837-2002
Mailing Address - Fax:850-837-8230
Practice Address - Street 1:12815 HWY 98 W
Practice Address - Street 2:SUITE 114
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550
Practice Address - Country:US
Practice Address - Phone:850-837-2002
Practice Address - Fax:850-837-8230
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist