Provider Demographics
NPI:1851792337
Name:EDWARDS, JENNA (LMT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 GLENWOOD DR APT 211
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1321
Mailing Address - Country:US
Mailing Address - Phone:253-380-8276
Mailing Address - Fax:
Practice Address - Street 1:10355 E ILIFF AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80247-3622
Practice Address - Country:US
Practice Address - Phone:303-755-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0015342225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist