Provider Demographics
NPI:1962944157
Name:JENNER, CORALIE (CMT, LMT, HHP)
Entity type:Individual
Prefix:
First Name:CORALIE
Middle Name:
Last Name:JENNER
Suffix:
Gender:F
Credentials:CMT, LMT, HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3533
Mailing Address - Country:US
Mailing Address - Phone:707-486-9846
Mailing Address - Fax:
Practice Address - Street 1:418 AVIATION BLVD STE D
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1074
Practice Address - Country:US
Practice Address - Phone:707-486-9846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-06
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 225700000X
CA74620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174H00000XOther Service ProvidersHealth Educator