Provider Demographics
NPI:1780243154
Name:WHTICOME, JACINTA (LMT)
Entity type:Individual
Prefix:
First Name:JACINTA
Middle Name:
Last Name:WHTICOME
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:NY
Mailing Address - Zip Code:14882-8802
Mailing Address - Country:US
Mailing Address - Phone:607-794-1071
Mailing Address - Fax:
Practice Address - Street 1:821 CLIFF ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2097
Practice Address - Country:US
Practice Address - Phone:607-256-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030978-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist