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General NPI Number Information
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NPI Number | 1235754086
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Entity Type | Individual
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Provider Name | JESSICA VIENNA WILSON L.M.T.
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Gender | Female
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Dates
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Enumeration Date | 06/08/2020
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Last Update Date | 06/08/2020
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Provider Practice Location Address
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Address Line | 13 RADNOR AVE FL 2
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City | CROTON ON HUDSON
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State | NY
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Zip | 10520-2621
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Country | US
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Telephone | 212-645-9067
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Fax |
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Provider Business Mailing Address
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Address Line | 13 RADNOR AVE FL 2
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City | CROTON ON HUDSON
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State | NY
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Zip | 10520-2621
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Country | US
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Telephone | 212-645-9067
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 017867
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License Number State | NY
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