Provider Demographics
NPI:1558852889
Name:VIRIVONG, JENNIFER (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VIRIVONG
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8650 MARTIN WAY E STE 207
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6610
Mailing Address - Country:US
Mailing Address - Phone:360-951-4504
Mailing Address - Fax:
Practice Address - Street 1:8650 MARTIN WAY E STE 207
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6610
Practice Address - Country:US
Practice Address - Phone:360-951-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist