Provider Demographics
NPI:1396879433
Name:MORENO, JESSELYN JURILLA
Entity type:Individual
Prefix:
First Name:JESSELYN
Middle Name:JURILLA
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSELYN
Other - Middle Name:SALLAVE
Other - Last Name:JURILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:247 WINDBROOKE LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7272
Mailing Address - Country:US
Mailing Address - Phone:757-490-5951
Mailing Address - Fax:
Practice Address - Street 1:1309 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2205
Practice Address - Country:US
Practice Address - Phone:757-461-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist