Provider Demographics
NPI:1831218221
Name:VISCOMI, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VISCOMI
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 1:3 TENNIS DR
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-3378
Mailing Address - Country:US
Mailing Address - Phone:508-845-3500
Mailing Address - Fax:508-845-7772
Practice Address - Street 1:3 TENNIS DR
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-3378
Practice Address - Country:US
Practice Address - Phone:508-845-3500
Practice Address - Fax:508-845-7772
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA 17848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA61701Medicare PIN