Provider Demographics
NPI:1043481393
Name:MANTLE, JAN L (LMP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:MANTLE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16244 13TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2814
Mailing Address - Country:US
Mailing Address - Phone:206-241-4625
Mailing Address - Fax:
Practice Address - Street 1:16244 13TH AVE SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2814
Practice Address - Country:US
Practice Address - Phone:206-241-4625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist