Provider Demographics
NPI:1467658229
Name:KNUTSON, JACLYN ANN (MA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANN
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LILLY RD NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98506-7400
Mailing Address - Country:US
Mailing Address - Phone:360-357-6314
Mailing Address - Fax:360-705-3745
Practice Address - Street 1:128 LILLY RD NE
Practice Address - Street 2:SUITE 202
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98506-7400
Practice Address - Country:US
Practice Address - Phone:360-357-6314
Practice Address - Fax:360-705-3745
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60192819237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALD60192819OtherWASHINGTON STATE DEPT OF HEALTH