Provider Demographics
NPI:1598305773
Name:JARVIS, LAUREN LEIGH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:LEIGH
Last Name:JARVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 NE KRESKY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2406
Mailing Address - Country:US
Mailing Address - Phone:360-996-4778
Mailing Address - Fax:360-996-4783
Practice Address - Street 1:2530 NE KRESKY AVE STE B
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2406
Practice Address - Country:US
Practice Address - Phone:360-996-4778
Practice Address - Fax:360-996-4783
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61033173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA61033173OtherLICENSE