Provider Demographics
NPI:1376058974
Name:REED- VAN WORMER, JERRINA (LMT)
Entity Type:Individual
Prefix:MS
First Name:JERRINA
Middle Name:
Last Name:REED- VAN WORMER
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:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-3395
Mailing Address - Country:US
Mailing Address - Phone:907-887-6647
Mailing Address - Fax:
Practice Address - Street 1:56610 E END RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-9572
Practice Address - Country:US
Practice Address - Phone:907-887-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK124837225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist