Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT.0014178 | CO |
NPI | 1013513464 |
---|---|
Provider Name | Jennifer Herman |
First Address | Marina Del Rey, CA 90292-5421 |
Second Address | Marina Del Rey, CA 90292-5421 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2020 |
Last Update Date | 10/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MT.0014178 | MASSAGE THERAPIST (01) | CO |