Provider Demographics
NPI:1336532530
Name:NELSON, JILL L (BS, LMT, CLT)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:BS, LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10410 KENSINGTON PKWY
Mailing Address - Street 2:STE 112
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2943
Mailing Address - Country:US
Mailing Address - Phone:240-347-1560
Mailing Address - Fax:
Practice Address - Street 1:10410 KENSINGTON PKWY
Practice Address - Street 2:STE 112
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2943
Practice Address - Country:US
Practice Address - Phone:240-347-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04211225700000X
DCMT1282225700000X
VACMT 0019008229225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist