Provider Demographics
NPI:1194007997
Name:WANER, JODIE L (LMP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:L
Last Name:WANER
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 1:2922 N WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4374
Mailing Address - Country:US
Mailing Address - Phone:509-590-7197
Mailing Address - Fax:
Practice Address - Street 1:3209 E 57TH AVE STE H
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7040
Practice Address - Country:US
Practice Address - Phone:509-448-9398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
60243875225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1267960OtherAMTA INSURANCE