Provider Demographics
NPI:1467293506
Name:EDENS, JESSICA B (EAMP, LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:EDENS
Suffix:
Gender:F
Credentials:EAMP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24770 TAREE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-8208
Mailing Address - Country:US
Mailing Address - Phone:903-267-3297
Mailing Address - Fax:
Practice Address - Street 1:24770 TAREE BLVD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-8208
Practice Address - Country:US
Practice Address - Phone:512-270-9468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC61377904171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist