Provider Demographics
NPI:1275851289
Name:TACEY, JON R (LMP)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:TACEY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SE MILE HILL DR STE A
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2962
Mailing Address - Country:US
Mailing Address - Phone:360-895-4844
Mailing Address - Fax:360-895-4834
Practice Address - Street 1:3100 SE MILE HILL DR STE A
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2962
Practice Address - Country:US
Practice Address - Phone:360-895-4844
Practice Address - Fax:360-895-4834
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60018860171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor