Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT122402 | TX |
NPI | 1003330945 |
---|---|
Provider Name | Jillyn Wall |
First Address | Colorado Springs, CO 80907-9441 |
Second Address | Colorado Springs, CO 80907-9441 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2017 |
Last Update Date | 02/08/2017 |