Provider Demographics
NPI:1174149629
Name:AMATO, JENNINE
Entity type:Individual
Prefix:
First Name:JENNINE
Middle Name:
Last Name:AMATO
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 1:307 COFFMAN ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 COFFMAN ST UNIT 3
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5470
Practice Address - Country:US
Practice Address - Phone:303-502-7695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist