Provider Demographics
NPI:1578358339
Name:RUDISILL, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RUDISILL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2079
Mailing Address - Country:US
Mailing Address - Phone:910-617-1663
Mailing Address - Fax:
Practice Address - Street 1:535 BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2079
Practice Address - Country:US
Practice Address - Phone:910-617-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13606225700000X
CA13606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist