Provider Demographics
NPI:1174689921
Name:HALBERG, JENNIFER AMY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:AMY
Last Name:HALBERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E LAURIDSEN BLVD
Mailing Address - Street 2:STE. 113
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7978
Mailing Address - Country:US
Mailing Address - Phone:360-808-4989
Mailing Address - Fax:360-452-8079
Practice Address - Street 1:430 E LAURIDSEN BLVD
Practice Address - Street 2:STE. 113
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7978
Practice Address - Country:US
Practice Address - Phone:360-808-4989
Practice Address - Fax:360-452-8079
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA7819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202248OtherLABOR AND INDUSTRIES
WAIR5507OtherREGENCE