Provider Demographics
NPI:1508681958
Name:RIEKEN, JENNIFER GRACE (MA61494004)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GRACE
Last Name:RIEKEN
Suffix:
Gender:F
Credentials:MA61494004
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9606 19TH AVE SE # 14
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3805
Mailing Address - Country:US
Mailing Address - Phone:425-870-4978
Mailing Address - Fax:
Practice Address - Street 1:630 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6622
Practice Address - Country:US
Practice Address - Phone:509-665-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61494004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist