Provider Demographics
NPI:1346762432
Name:LARREYNAGA, JENNIFER JEANNE (MA 60763617)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEANNE
Last Name:LARREYNAGA
Suffix:
Gender:F
Credentials:MA 60763617
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7508 HILL AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1211
Mailing Address - Country:US
Mailing Address - Phone:619-730-8316
Mailing Address - Fax:
Practice Address - Street 1:3715 56TH ST NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8240
Practice Address - Country:US
Practice Address - Phone:253-851-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60763617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist