MEDICARE: JENNIFER MCQUADE WILSON LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA37275	FL

General Provider Information

NPI Number	:	1659627578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MCQUADE WILSON LMT

Provider Business Mailing Address
First Line	:	3232 COVENTRY N
Second Line	:
City	:	SAFETY HARBOR
State	:	FL
Zip	:	34695-4807
Country	:	US
Telephone Number	:	727-599-6772
Fax Number	:

Provider Business Practice Location Address
First Line	:	1153 NE CLEVELAND ST
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33755-4815
Country	:	US
Telephone Number	:	727-599-6772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2012
Last Update Date	:	07/29/2012

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