MEDICARE: MS. JENNIFER MARIE BOUDREAU LMP, AS

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	MA00023514	WA

General Provider Information

NPI Number	:	1477681518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER MARIE BOUDREAU LMP, AS

Provider Business Mailing Address
First Line	:	383 SUDDEN VLY
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98229-4807
Country	:	US
Telephone Number	:	360-393-9923
Fax Number	:	360-527-9469

Provider Business Practice Location Address
First Line	:	119 N COMMERCIAL ST
Second Line	:	SUITE 415
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-4446
Country	:	US
Telephone Number	:	360-393-9923
Fax Number	:	360-527-9469

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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