Provider Demographics
NPI:1487814828
Name:WILSON, JANE ELSPETH (CMT, LMT, AMT)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ELSPETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:CMT, LMT, AMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 BURTIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702-2703
Mailing Address - Country:US
Mailing Address - Phone:757-237-6214
Mailing Address - Fax:
Practice Address - Street 1:39 BURTIS ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23702-2703
Practice Address - Country:US
Practice Address - Phone:757-237-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019004946172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist