Provider Demographics
NPI:1346694007
Name:VANDERSTOUW, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANDERSTOUW
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 1:3201 N 38TH ST UNIT 27
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6358
Mailing Address - Country:US
Mailing Address - Phone:480-283-5243
Mailing Address - Fax:
Practice Address - Street 1:1615 E WARNER RD STE 3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-4500
Practice Address - Country:US
Practice Address - Phone:480-283-5243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-12206225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist