Provider Demographics
NPI:1487821328
Name:GAGNON, JENNIFER J (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:GAGNON
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 1:2376 MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-8605
Mailing Address - Country:US
Mailing Address - Phone:360-384-2900
Mailing Address - Fax:360-384-2955
Practice Address - Street 1:2376 MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-8605
Practice Address - Country:US
Practice Address - Phone:360-384-2900
Practice Address - Fax:360-384-2955
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015259225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist