Provider Demographics
NPI:1528363470
Name:ANDERSON, JENNIFER (NCTMB)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NCTMB
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 1413
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-1413
Mailing Address - Country:US
Mailing Address - Phone:970-389-6103
Mailing Address - Fax:970-513-0818
Practice Address - Street 1:325 LAKE DILLON DRIVE
Practice Address - Street 2:STE 104
Practice Address - City:DILLON
Practice Address - State:CO
Practice Address - Zip Code:80435
Practice Address - Country:US
Practice Address - Phone:970-389-6103
Practice Address - Fax:970-513-0818
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist