Provider Demographics
NPI:1497061006
Name:COLBERT, JENNIFER L (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:COLBERT
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 1:811 NW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3247
Mailing Address - Country:US
Mailing Address - Phone:360-624-1880
Mailing Address - Fax:
Practice Address - Street 1:811 NW 13TH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-3247
Practice Address - Country:US
Practice Address - Phone:360-624-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60156857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist