Provider Demographics
NPI:1164004172
Name:JEWELL, MICHAEL JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:JEWELL
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 1:6050 TACOMA MALL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6828
Mailing Address - Country:US
Mailing Address - Phone:253-581-5200
Mailing Address - Fax:253-581-5203
Practice Address - Street 1:2727 HOLLYCROFT ST STE 310
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1312
Practice Address - Country:US
Practice Address - Phone:253-514-6757
Practice Address - Fax:253-432-4075
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist