Provider Demographics
NPI:1790969533
Name:JUSTESEN, JENNIFER
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:JUSTESEN
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 1:2200 S MAIERS RD APT B
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8818
Mailing Address - Country:US
Mailing Address - Phone:509-764-8626
Mailing Address - Fax:509-764-8628
Practice Address - Street 1:2200 S MAIERS RD APT B
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-8818
Practice Address - Country:US
Practice Address - Phone:509-764-8626
Practice Address - Fax:509-764-8628
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023354174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist