Provider Demographics
NPI:1245443324
Name:LIBOLT, JESSICA LYNN (LMP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:LIBOLT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 GROVER ST STE B2
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1539
Mailing Address - Country:US
Mailing Address - Phone:360-815-0317
Mailing Address - Fax:
Practice Address - Street 1:1610 GROVER ST STE B2
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1539
Practice Address - Country:US
Practice Address - Phone:360-815-0317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020149225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist