Provider Demographics
NPI:1336787118
Name:WARNER-JENNINGS, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WARNER-JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 COFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2724
Mailing Address - Country:US
Mailing Address - Phone:612-616-5538
Mailing Address - Fax:
Practice Address - Street 1:630 15TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2764
Practice Address - Country:US
Practice Address - Phone:303-651-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0015797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist