Provider Demographics
NPI:1134270705
Name:WATTERS, JENNIFER JOANNE (LMP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOANNE
Last Name:WATTERS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:JOANNE
Other - Last Name:COLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2176
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584
Mailing Address - Country:US
Mailing Address - Phone:360-426-8060
Mailing Address - Fax:360-427-5819
Practice Address - Street 1:1635 OLYMPIC HIGHWAY N
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-426-8060
Practice Address - Fax:360-427-5819
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014451225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0203230OtherLABOR & INDUSTRIES