Provider Demographics
NPI:1497164479
Name:RILEY, JESSICA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-7076
Mailing Address - Country:US
Mailing Address - Phone:304-844-2368
Mailing Address - Fax:
Practice Address - Street 1:1913 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-7076
Practice Address - Country:US
Practice Address - Phone:304-844-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20112905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist