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General NPI Number Information
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NPI Number | 1336586304
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Entity Type | Organization
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Legal Business Name | JENNIFER M FRASER
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Dates
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Enumeration Date | 05/30/2013
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Last Update Date | 05/30/2013
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Provider Practice Location Address
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Address Line | 109 NW 1ST AVE
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City | KELSO
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State | WA
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Zip | 98626-1726
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Country | US
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Telephone | 360-423-3132
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Fax | 360-423-1890
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Provider Business Mailing Address
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Address Line | 109 NW 1ST AVE
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City | KELSO
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State | WA
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Zip | 98626-1726
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Country | US
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Telephone | 360-423-3132
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Fax | 360-423-1890
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JENNIFER MARIE HAULK-FRASER
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Credential | LMP
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Telephone | 360-423-3132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA00017762
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License Number State | WA
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