Provider Demographics
NPI:1083741458
Name:MAXWELL, JENNIFER CULVER (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CULVER
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:HEATHER
Other - Last Name:CULVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:844 55TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-1201
Mailing Address - Country:US
Mailing Address - Phone:360-531-2705
Mailing Address - Fax:
Practice Address - Street 1:2140 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-7925
Practice Address - Country:US
Practice Address - Phone:360-531-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020718225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0195858OtherLNI PROVIDER NUMBER