Provider Demographics
NPI:1265642847
Name:PHOENIX, JASMINE (LMP)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:PHOENIX
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 1:2051 P.O. BOX 257
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0257
Mailing Address - Country:US
Mailing Address - Phone:360-708-0243
Mailing Address - Fax:
Practice Address - Street 1:12263 NORTH MILL STREET
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WA
Practice Address - Zip Code:98235
Practice Address - Country:US
Practice Address - Phone:360-856-5354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00000839225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0158184OtherLABOR AND INDUSTRIES