Provider Demographics
NPI:1649746298
Name:WEAVER, JENNIFER (MMT, LMT, CPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MMT, LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131884
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77393-1884
Mailing Address - Country:US
Mailing Address - Phone:832-868-4941
Mailing Address - Fax:
Practice Address - Street 1:2975 MILL BAY RD
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-7831
Practice Address - Country:US
Practice Address - Phone:907-512-0809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK137164225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty