Provider Demographics
NPI:1114479573
Name:WOLBACH, JENNIFER LEE (CPO)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:WOLBACH
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:FRALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:317 WELLSIAN WAY
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4116
Mailing Address - Country:US
Mailing Address - Phone:509-943-8561
Mailing Address - Fax:509-943-1037
Practice Address - Street 1:317 WELLSIAN WAY
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4116
Practice Address - Country:US
Practice Address - Phone:095-943-8561
Practice Address - Fax:509-943-1037
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114479573Medicaid