Provider Demographics
NPI:1881696805
Name:PENROSE, JENNIFER E (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:E
Last Name:PENROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 GALAXY DR NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4746
Mailing Address - Country:US
Mailing Address - Phone:360-456-1444
Mailing Address - Fax:360-456-1883
Practice Address - Street 1:1445 GALAXY DR NE
Practice Address - Street 2:SUITE 301
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4746
Practice Address - Country:US
Practice Address - Phone:360-456-1444
Practice Address - Fax:360-456-1883
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8342131Medicaid
WA0222918OtherLABOR AND INDUSTRIES
WA8342131Medicaid