Provider Demographics
NPI:1275691859
Name:JACKA, JULIE MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:MARIE
Last Name:JACKA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:GOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 W GRAVES
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218
Mailing Address - Country:US
Mailing Address - Phone:509-466-6106
Mailing Address - Fax:509-466-2925
Practice Address - Street 1:14 W GRAVES
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218
Practice Address - Country:US
Practice Address - Phone:509-466-6106
Practice Address - Fax:509-466-2925
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA12489225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist