Provider Demographics
NPI:1043463011
Name:REID, JENNIFER (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:REID
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KORNELIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:1229 CORNWALL AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5023
Mailing Address - Country:US
Mailing Address - Phone:360-820-0334
Mailing Address - Fax:
Practice Address - Street 1:1229 CORNWALL AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5023
Practice Address - Country:US
Practice Address - Phone:360-820-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60015176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist