Provider Demographics
NPI:1508490970
Name:IGLESIAS, JENICA FAYE SALVADOR
Entity Type:Individual
Prefix:
First Name:JENICA FAYE
Middle Name:SALVADOR
Last Name:IGLESIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17404 60TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-2835
Mailing Address - Country:US
Mailing Address - Phone:425-905-4150
Mailing Address - Fax:
Practice Address - Street 1:17404 60TH AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-2835
Practice Address - Country:US
Practice Address - Phone:425-905-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61027122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist