Basic Information
| Provider Information | |||||||||
| NPI: | 1699175224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLDEN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | BLAIR WALSH | ||||||||
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| OtherLastName: | WALSH | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | BLAIR | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 VICTORY RD | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021713139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177741490 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 VICTORY RD | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021713139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177741490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2014 | ||||||||
| LastUpdateDate: | 09/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.