Provider Demographics
NPI:1164087896
Name:TALLEY, JAMIE CHRISTINA
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:CHRISTINA
Last Name:TALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MCINTYRE RD
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9358
Mailing Address - Country:US
Mailing Address - Phone:360-470-3511
Mailing Address - Fax:
Practice Address - Street 1:201 S. 3RD STREET
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-470-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60934875225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60934875OtherSTATE OF WASHINGTON