Provider Demographics
NPI:1104011204
Name:TANNER, JENNIFER MARLENE (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARLENE
Last Name:TANNER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N MISSION ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2065
Mailing Address - Country:US
Mailing Address - Phone:509-662-4711
Mailing Address - Fax:509-662-2800
Practice Address - Street 1:610 N MISSION ST STE 102
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2065
Practice Address - Country:US
Practice Address - Phone:509-662-4711
Practice Address - Fax:509-662-2800
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020951225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist