MEDICARE: JENNIFER DOHERTY RMT, MBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT-7646	CO

General Provider Information

NPI Number	:	1033413216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DOHERTY RMT, MBA

Provider Business Mailing Address
First Line	:	138 CREEKSIDE LN
Second Line	:	APT. 104
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3267
Country	:	US
Telephone Number	:	719-271-9663
Fax Number	:

Provider Business Practice Location Address
First Line	:	4755 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4255
Country	:	US
Telephone Number	:	719-271-9663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2011
Last Update Date	:	01/03/2011

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