Provider Demographics
NPI:1811417215
Name:VIOLA, JESSICA LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:VIOLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3364
Mailing Address - Country:US
Mailing Address - Phone:718-865-7020
Mailing Address - Fax:
Practice Address - Street 1:1154 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3623
Practice Address - Country:US
Practice Address - Phone:718-865-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006023171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty