Provider Demographics
NPI:1588032338
Name:JENSEN, LARA (LMT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 ALDER AVE
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-1406
Mailing Address - Country:US
Mailing Address - Phone:253-250-5151
Mailing Address - Fax:
Practice Address - Street 1:918 ALDER AVE
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1406
Practice Address - Country:US
Practice Address - Phone:253-250-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60597662225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist