Provider Demographics
NPI:1720815954
Name:MARCUCCI, JENNIFER ALLINE (LMT 1415)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALLINE
Last Name:MARCUCCI
Suffix:
Gender:F
Credentials:LMT 1415
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3494
Mailing Address - Country:US
Mailing Address - Phone:601-337-5609
Mailing Address - Fax:
Practice Address - Street 1:138 E FRONT ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3494
Practice Address - Country:US
Practice Address - Phone:601-337-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1415225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist