Provider Demographics
NPI:1295857639
Name:HENLINE, J LINN BLACK (LMP, SAMP)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:LINN BLACK
Last Name:HENLINE
Suffix:
Gender:F
Credentials:LMP, SAMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3197
Mailing Address - Country:US
Mailing Address - Phone:425-673-9573
Mailing Address - Fax:
Practice Address - Street 1:316 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3197
Practice Address - Country:US
Practice Address - Phone:425-673-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016564172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist