Provider Demographics
NPI:1922337740
Name:WILSON, JESSICA NAOMI (LMP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NAOMI
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33427 PACIFIC HWY S STE C1
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6897
Mailing Address - Country:US
Mailing Address - Phone:253-874-2498
Mailing Address - Fax:253-248-1909
Practice Address - Street 1:33427 PACIFIC HWY S STE C1
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6897
Practice Address - Country:US
Practice Address - Phone:253-874-2498
Practice Address - Fax:253-248-1909
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60116001225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist