Provider Demographics
NPI:1407280597
Name:VANDERBLOOM, JANESSA MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:JANESSA
Middle Name:MARIE
Last Name:VANDERBLOOM
Suffix:
Gender:F
Credentials:LMP
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 4665
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-4011
Mailing Address - Country:US
Mailing Address - Phone:509-967-5650
Mailing Address - Fax:509-967-2900
Practice Address - Street 1:4791 W VAN GIESEN ST STE B
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-5085
Practice Address - Country:US
Practice Address - Phone:509-967-2225
Practice Address - Fax:509-967-2900
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60397426225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist