Healthcare Provider Details

I. General information

NPI: 1326376823
Provider Name (Legal Business Name): JENNIFER NICOLE FARRELLY LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 POGUE LN
CASTLE ROCK WA
98611-9391
US

IV. Provider business mailing address

220 POGUE LN
CASTLE ROCK WA
98611-9391
US

V. Phone/Fax

Practice location:
  • Phone: 360-441-0917
  • Fax:
Mailing address:
  • Phone: 360-441-0917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60118681
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: