Provider Demographics
NPI:1528197910
Name:CONRAD, JENNIFER L (LMP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CONRAD
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 1:7423 114TH ST E # B
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-7866
Mailing Address - Country:US
Mailing Address - Phone:253-820-3641
Mailing Address - Fax:253-845-5753
Practice Address - Street 1:11108 WOODLAND AVE E STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5893
Practice Address - Country:US
Practice Address - Phone:253-845-5358
Practice Address - Fax:253-845-5753
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017265225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00017265OtherSTATE LICENSE
WA0190641OtherLABOR & INDUSTRIES