Provider Demographics
NPI:1265169445
Name:RADEMAN, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:RADEMAN
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 1:125 APPLE VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6912
Mailing Address - Country:US
Mailing Address - Phone:509-939-0077
Mailing Address - Fax:
Practice Address - Street 1:5504 S CUSTER RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-1627
Practice Address - Country:US
Practice Address - Phone:509-981-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-06
Last Update Date:2024-11-20
Deactivation Date:2023-01-27
Deactivation Code:
Reactivation Date:2024-11-20
Provider Licenses
StateLicense IDTaxonomies
WADH60760955124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist