Provider Demographics
NPI:1427301977
Name:WICKERSHAM, JENNIFER LYNN (LMP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:WICKERSHAM
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 1:2734 PINE RD NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2120
Mailing Address - Country:US
Mailing Address - Phone:360-536-6114
Mailing Address - Fax:
Practice Address - Street 1:5610 KITSAP WAY
Practice Address - Street 2:SUITE 260
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-2292
Practice Address - Country:US
Practice Address - Phone:360-478-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018998225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist