Provider Demographics
NPI:1356922082
Name:RIVAS, JESSIKA L
Entity type:Individual
Prefix:
First Name:JESSIKA
Middle Name:L
Last Name:RIVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 JENNINGS ST
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4535
Mailing Address - Country:US
Mailing Address - Phone:703-568-0679
Mailing Address - Fax:
Practice Address - Street 1:9902 LIBERIA AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-7052
Practice Address - Country:US
Practice Address - Phone:703-568-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019017207225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist