Provider Demographics
NPI:1679310254
Name:JESSICA JEWEL LLC
Entity type:Organization
Organization Name:JESSICA JEWEL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-322-0662
Mailing Address - Street 1:4561 LEHIGH DR
Mailing Address - Street 2:
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-9510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4561 LEHIGH DR
Practice Address - Street 2:
Practice Address - City:WALNUTPORT
Practice Address - State:PA
Practice Address - Zip Code:18088-9510
Practice Address - Country:US
Practice Address - Phone:713-822-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health