MEDICARE: JENNIFER KATHLEEN CROLEY LMP

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	172V00000X	Community Health Worker	MA 00023965	WA

General Provider Information

NPI Number	:	1124269360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER KATHLEEN CROLEY LMP

Provider Business Mailing Address
First Line	:	313 5TH AVE SE STE B
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98501-1191
Country	:	US
Telephone Number	:	360-357-6953
Fax Number	:

Provider Business Practice Location Address
First Line	:	2407 WASHINGTON ST SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98501-2960
Country	:	US
Telephone Number	:	360-918-6155
Fax Number	:

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

Provider Enumeration Date	:	03/18/2009
Last Update Date	:	03/18/2009

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