Provider Demographics
NPI:1740935774
Name:BRASSELERO, JESSICA (MT0019686)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRASSELERO
Suffix:
Gender:F
Credentials:MT0019686
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 TIDEWATER LN
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-3554
Mailing Address - Country:US
Mailing Address - Phone:970-646-2872
Mailing Address - Fax:
Practice Address - Street 1:631 BIRCH ST UNIT D
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5053
Practice Address - Country:US
Practice Address - Phone:970-646-2872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0019686225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist