Provider Demographics
NPI:1437709961
Name:SHOOT, JAMIL VAUGHN (EAMP, LAC, LMT)
Entity Type:Individual
Prefix:
First Name:JAMIL
Middle Name:VAUGHN
Last Name:SHOOT
Suffix:
Gender:M
Credentials:EAMP, LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-0101
Mailing Address - Country:US
Mailing Address - Phone:425-242-6006
Mailing Address - Fax:
Practice Address - Street 1:21705 56TH AVE W
Practice Address - Street 2:
Practice Address - City:MOUNT LAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043
Practice Address - Country:US
Practice Address - Phone:425-242-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60585565225700000X
WAAC60966029171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist