Provider Demographics
NPI:1033255336
Name:ADCOCK, JIMMY LEE (LMP)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:ADCOCK
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 S EARLY DAWN CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-9385
Mailing Address - Country:US
Mailing Address - Phone:509-475-7395
Mailing Address - Fax:
Practice Address - Street 1:327 W 8TH AVE STE 222
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2557
Practice Address - Country:US
Practice Address - Phone:509-624-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019287225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0184210OtherLABOR AND INDUSTRIES