Provider Demographics
NPI:1477687044
Name:ANDRULLI, JENNIFER R (MT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:R
Last Name:ANDRULLI
Suffix:
Gender:F
Credentials:MT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:ANDRULLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMT
Mailing Address - Street 1:35555 KENAI SPUR HWY # 317
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7674
Mailing Address - Country:US
Mailing Address - Phone:907-365-9845
Mailing Address - Fax:833-922-1869
Practice Address - Street 1:3800 LAKE OTIS PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5237
Practice Address - Country:US
Practice Address - Phone:907-365-9845
Practice Address - Fax:833-922-1869
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK721989225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist