Provider Demographics
NPI:1548921927
Name:SWENSON, JENNIFER SUSAN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:SWENSON
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:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:MATLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98560-0279
Mailing Address - Country:US
Mailing Address - Phone:360-589-3889
Mailing Address - Fax:
Practice Address - Street 1:119 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MCCLEARY
Practice Address - State:WA
Practice Address - Zip Code:98557-9652
Practice Address - Country:US
Practice Address - Phone:360-482-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61167540225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty