Provider Demographics
NPI:1255649869
Name:JANDOC, JAMES KIMO (OMT, LMT, STMS)
Entity Type:Individual
Prefix:
First Name:JAMES KIMO
Middle Name:
Last Name:JANDOC
Suffix:
Gender:M
Credentials:OMT, LMT, STMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 WESTVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-8578
Mailing Address - Country:US
Mailing Address - Phone:360-510-4630
Mailing Address - Fax:360-935-9731
Practice Address - Street 1:1610 GROVER ST STE C3
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264
Practice Address - Country:US
Practice Address - Phone:360-510-4630
Practice Address - Fax:360-935-9731
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015681208100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0152465OtherWASHINGTON STATE DEPARTMENT OF LABOR AND INDUSTRY