Healthcare Provider Details

I. General information

NPI: 1013353713
Provider Name (Legal Business Name): JENNIFER LOVELL WILSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W 2ND AVE
INDIANOLA IA
50125-2522
US

IV. Provider business mailing address

508 E 3RD AVE
INDIANOLA IA
50125-2945
US

V. Phone/Fax

Practice location:
  • Phone: 515-962-2166
  • Fax:
Mailing address:
  • Phone: 319-202-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number005932
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: