Provider Demographics
NPI:1124269360
Name:CROLEY, JENNIFER KATHLEEN (LMP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:CROLEY
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 1:313 5TH AVE SE STE B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1191
Mailing Address - Country:US
Mailing Address - Phone:360-357-6953
Mailing Address - Fax:
Practice Address - Street 1:2407 WASHINGTON ST SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2960
Practice Address - Country:US
Practice Address - Phone:360-918-6155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00023965172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker