Provider Demographics
NPI:1366045148
Name:RILEY, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RILEY
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 1:217 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 STANTON CHRISTIANA RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2198
Practice Address - Country:US
Practice Address - Phone:443-967-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0004579225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist