Provider Demographics
NPI:1538646831
Name:HUSOM, JESSICA L (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:HUSOM
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 1:1744 SUNSHINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-8729
Mailing Address - Country:US
Mailing Address - Phone:509-771-1278
Mailing Address - Fax:
Practice Address - Street 1:1744 SUNSHINE AVE
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-8729
Practice Address - Country:US
Practice Address - Phone:509-771-1278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60872205225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist