Provider Demographics
NPI:1972957959
Name:WHITEHEAD, JESSICA NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 HONEYSUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2849
Mailing Address - Country:US
Mailing Address - Phone:978-390-5019
Mailing Address - Fax:
Practice Address - Street 1:2315 BEL AIR RD
Practice Address - Street 2:
Practice Address - City:FALLSTON
Practice Address - State:MD
Practice Address - Zip Code:21047-2740
Practice Address - Country:US
Practice Address - Phone:443-417-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDA00010122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program