Provider Demographics
NPI:1225840648
Name:BLAND, JALISA (LMT, MMP)
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:BLAND
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74952
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-0016
Mailing Address - Country:US
Mailing Address - Phone:434-264-2383
Mailing Address - Fax:
Practice Address - Street 1:900 ST JAMES ST UNIT 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-2511
Practice Address - Country:US
Practice Address - Phone:434-264-2383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019019701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist