Provider Demographics
NPI:1669683702
Name:HOLLOWAY-LARSEN, JESSICA LYNN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:HOLLOWAY-LARSEN
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 1:24530 138TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-7275
Mailing Address - Country:US
Mailing Address - Phone:360-393-7814
Mailing Address - Fax:425-783-0404
Practice Address - Street 1:5131 COLBY AVE STE B
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-3355
Practice Address - Country:US
Practice Address - Phone:425-783-0404
Practice Address - Fax:425-783-0404
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021205225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist