Provider Demographics
NPI:1760053474
Name:TREVINO, JESSICA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TREVINO
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 1:3701 QUICK HILL RD APT 14207
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-1300
Mailing Address - Country:US
Mailing Address - Phone:512-426-2774
Mailing Address - Fax:
Practice Address - Street 1:3701 QUICK HILL RD APT 14207
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-1300
Practice Address - Country:US
Practice Address - Phone:512-426-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-03
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT129291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT129291OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION