Provider Demographics
NPI:1801345475
Name:ROSENBAUM, JENNIFER RAY (LMP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAY
Last Name:ROSENBAUM
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 1:321 FOREST PARK RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-7204
Mailing Address - Country:US
Mailing Address - Phone:360-721-6321
Mailing Address - Fax:
Practice Address - Street 1:321 FOREST PARK RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-7204
Practice Address - Country:US
Practice Address - Phone:360-721-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60607972174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist