Provider Demographics
NPI:1518208636
Name:CORDOVA, JENNY (LMP)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:JENY
Other - Middle Name:
Other - Last Name:CORDOVA-MONTIEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:626 TERRACE ST APT 8
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2138
Mailing Address - Country:US
Mailing Address - Phone:425-345-0697
Mailing Address - Fax:
Practice Address - Street 1:211 W HILL ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1404
Practice Address - Country:US
Practice Address - Phone:360-794-6620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60288143225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist