Provider Demographics
NPI:1053489880
Name:RADNER, JAMIE P (LIC AC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:P
Last Name:RADNER
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6805 NE EISENHARDT LN
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7759
Mailing Address - Country:US
Mailing Address - Phone:360-471-4805
Mailing Address - Fax:
Practice Address - Street 1:19041 FRONT ST.
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370
Practice Address - Country:US
Practice Address - Phone:360-471-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230123171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist