Provider Demographics
NPI:1801384185
Name:CONLEY, JENNIFER BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOKE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25720 MAPLE VALLEY BLACK DIAMOND RD SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-8313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25720 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8313
Practice Address - Country:US
Practice Address - Phone:425-413-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160465758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP160465758OtherWASHINGTON STATE DEPARTMENT OF HEALTH