Provider Demographics
NPI:1568650182
Name:MALO, JENNIFER LOUISE (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:MALO
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 1:18223 80TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-9719
Mailing Address - Country:US
Mailing Address - Phone:253-875-9504
Mailing Address - Fax:
Practice Address - Street 1:18223 80TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-9719
Practice Address - Country:US
Practice Address - Phone:253-875-9504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021417172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker