Provider Demographics
NPI:1104037860
Name:BLACK, JOLEEN DENISE (LMT)
Entity Type:Individual
Prefix:
First Name:JOLEEN
Middle Name:DENISE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8827 31ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3718
Mailing Address - Country:US
Mailing Address - Phone:206-841-4031
Mailing Address - Fax:206-973-2747
Practice Address - Street 1:8827 31ST AVE SW # 1
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3718
Practice Address - Country:US
Practice Address - Phone:206-841-4031
Practice Address - Fax:206-973-2747
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020122225700000X
WAAC60530881171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA219893OtherLABOR AND INDUSTRY