Provider Demographics
NPI:1275757197
Name:BOUCEK, JILLIAN M (LMP)
Entity Type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:M
Last Name:BOUCEK
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 1:15212 SE 276TH PL
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4389
Mailing Address - Country:US
Mailing Address - Phone:425-829-8737
Mailing Address - Fax:
Practice Address - Street 1:19030 108TH AVE SE
Practice Address - Street 2:STE 1
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6425
Practice Address - Country:US
Practice Address - Phone:425-282-5048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011013172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist