Provider Demographics
NPI:1437666526
Name:VLISIDES-HENRY, JESSICA ALYSSE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALYSSE
Last Name:VLISIDES-HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4374 S MAIN ST UNIT 520
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3377
Mailing Address - Country:US
Mailing Address - Phone:248-410-4677
Mailing Address - Fax:
Practice Address - Street 1:2330 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1304
Practice Address - Country:US
Practice Address - Phone:248-410-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11323315-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program