Provider Demographics
NPI:1124512371
Name:WIERSMA, JENNIFER LYNN (LMT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:WIERSMA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 VILLA CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-8911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:346 SE 5TH AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-5209
Practice Address - Country:US
Practice Address - Phone:561-703-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43137225700000X, 204C00000X
MA43137173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173C00000XOther Service ProvidersReflexologistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty