Provider Demographics
NPI:1083106892
Name:JOSE-JOSE, JOVANNY (LMT)
Entity Type:Individual
Prefix:
First Name:JOVANNY
Middle Name:
Last Name:JOSE-JOSE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 MERCEDES PL UNIT 202
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-3921
Mailing Address - Country:US
Mailing Address - Phone:360-201-6160
Mailing Address - Fax:
Practice Address - Street 1:1901 N STATE ST STE C
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4645
Practice Address - Country:US
Practice Address - Phone:360-650-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60848136225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist