Provider Demographics
NPI:1568668960
Name:NOTTINGHAM, JENNIFER KELLI (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KELLI
Last Name:NOTTINGHAM
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 1:2501 SE MILE HILL DR STE A101
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3514
Mailing Address - Country:US
Mailing Address - Phone:360-620-8943
Mailing Address - Fax:
Practice Address - Street 1:2501 SE MILE HILL DR STE A101
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3514
Practice Address - Country:US
Practice Address - Phone:360-620-8943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist