Provider Demographics
NPI:1598582363
Name:STORM-ALVES, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STORM-ALVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 OTTER BROOK LOOP
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-1853
Mailing Address - Country:US
Mailing Address - Phone:614-352-5227
Mailing Address - Fax:
Practice Address - Street 1:3639 OTTER BROOK LOOP
Practice Address - Street 2:
Practice Address - City:DISCOVERY BAY
Practice Address - State:CA
Practice Address - Zip Code:94505-1853
Practice Address - Country:US
Practice Address - Phone:614-352-5227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23353225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist