Provider Demographics
NPI:1306050125
Name:KUDUK, JENNIFER CAROLE (LMP)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:CAROLE
Last Name:KUDUK
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 1:8605 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2919
Mailing Address - Country:US
Mailing Address - Phone:206-369-1502
Mailing Address - Fax:
Practice Address - Street 1:5649 UNIVERSITY WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2619
Practice Address - Country:US
Practice Address - Phone:206-369-1502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist