Provider Demographics
NPI:1134279656
Name:MATHIS, JANA MARIE (LMP)
Entity Type:Individual
Prefix:MS
First Name:JANA
Middle Name:MARIE
Last Name:MATHIS
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 1:11429 81ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3558
Mailing Address - Country:US
Mailing Address - Phone:425-829-7517
Mailing Address - Fax:
Practice Address - Street 1:11801 NE 160TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-4106
Practice Address - Country:US
Practice Address - Phone:425-488-3477
Practice Address - Fax:425-481-8031
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012432174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist