Provider Demographics
NPI:1134754526
Name:SMITH, JENNIFER WESTON (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WESTON
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WESTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1829 NE 58TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-2440
Mailing Address - Country:US
Mailing Address - Phone:206-915-0972
Mailing Address - Fax:
Practice Address - Street 1:1829 NE 58TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2440
Practice Address - Country:US
Practice Address - Phone:805-996-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61004978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA61004978OtherMASSAGE LICENSE