Provider Demographics
NPI:1922379635
Name:LILLY, JESSICA LYNN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYNN
Last Name:LILLY
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 W. 27TH AVENUE
Mailing Address - Street 2:SUITE E
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338
Mailing Address - Country:US
Mailing Address - Phone:509-783-0834
Mailing Address - Fax:509-987-1090
Practice Address - Street 1:4303 W. 27TH AVENUE
Practice Address - Street 2:SUITE E
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338
Practice Address - Country:US
Practice Address - Phone:509-783-0834
Practice Address - Fax:509-987-1090
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60213735172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker