Provider Demographics
NPI:1447385919
Name:ROEDER, JENNIFER SUE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUE
Last Name:ROEDER
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 1:100 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1602
Mailing Address - Country:US
Mailing Address - Phone:509-754-9374
Mailing Address - Fax:509-754-9374
Practice Address - Street 1:100 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-1602
Practice Address - Country:US
Practice Address - Phone:509-754-9374
Practice Address - Fax:509-754-9374
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014198225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist