MEDICARE: JENNIFER LYNNE WAGGONER 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	225700000X	Massage Therapist	MA00023736	WA

General Provider Information

NPI Number	:	1770788853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LYNNE WAGGONER LMP

Provider Business Mailing Address
First Line	:	30919 NE SPRING HILL RD
Second Line	:
City	:	YACOLT
State	:	WA
Zip	:	98675-3004
Country	:	US
Telephone Number	:	360-635-8284
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 W 39TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660-1974
Country	:	US
Telephone Number	:	360-635-8284
Fax Number	:

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

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	07/08/2007

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