Provider Demographics
NPI:1588924385
Name:WHALEY-JOHNSTON, JESSICA (LAC, MSTOM,DIPLOM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WHALEY-JOHNSTON
Suffix:
Gender:F
Credentials:LAC, MSTOM,DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MASPETH AVE APT 3N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-2564
Mailing Address - Country:US
Mailing Address - Phone:347-276-1213
Mailing Address - Fax:
Practice Address - Street 1:214 W 29TH ST
Practice Address - Street 2:SUITE 901
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5203
Practice Address - Country:US
Practice Address - Phone:347-276-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004829171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist