Provider Demographics
NPI:1588170708
Name:VAN PELT, JENNIFER WALTERS (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WALTERS
Last Name:VAN PELT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S SYRACUSE WAY
Mailing Address - Street 2:10-203
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-4294
Mailing Address - Country:US
Mailing Address - Phone:303-968-9971
Mailing Address - Fax:
Practice Address - Street 1:2800 S SYRACUSE WAY
Practice Address - Street 2:10-203
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-4294
Practice Address - Country:US
Practice Address - Phone:303-968-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0019858225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist