Provider Demographics
NPI:1457660011
Name:PEDERSEN, JESSICA LYN (BS, LMT)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYN
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:BS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 N WELLWOOD AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4046
Mailing Address - Country:US
Mailing Address - Phone:631-835-3600
Mailing Address - Fax:
Practice Address - Street 1:152 N WELLWOOD AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4046
Practice Address - Country:US
Practice Address - Phone:631-835-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist