Provider Demographics
NPI:1639650336
Name:ANDERSON, JENNEVIEVE MOON (LMT)
Entity Type:Individual
Prefix:MS
First Name:JENNEVIEVE
Middle Name:MOON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:21 BELLWETHER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2961
Mailing Address - Country:US
Mailing Address - Phone:360-502-7548
Mailing Address - Fax:360-797-9647
Practice Address - Street 1:21 BELLWETHER WAY STE 101
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2961
Practice Address - Country:US
Practice Address - Phone:360-502-7548
Practice Address - Fax:360-797-9647
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60813804225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist