Provider Demographics
NPI:1659505212
Name:KRUSE, JENELL LYNN (LMP)
Entity Type:Individual
Prefix:
First Name:JENELL
Middle Name:LYNN
Last Name:KRUSE
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:PO BOX 685
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-0685
Mailing Address - Country:US
Mailing Address - Phone:509-826-2894
Mailing Address - Fax:
Practice Address - Street 1:6 QUAIL RUN WAY
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840
Practice Address - Country:US
Practice Address - Phone:509-826-2894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60076314225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist