Provider Demographics
NPI:1659654317
Name:HESSE, JERILYNN LILES (LMBT)
Entity type:Individual
Prefix:MRS
First Name:JERILYNN
Middle Name:LILES
Last Name:HESSE
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 OLDRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1115
Mailing Address - Country:US
Mailing Address - Phone:704-542-2541
Mailing Address - Fax:
Practice Address - Street 1:3711 OLDRIDGE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1115
Practice Address - Country:US
Practice Address - Phone:704-542-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2985225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist