Provider Demographics
NPI:1477942860
Name:STANLEY, JOHNATHAN (LMP)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:STANLEY
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 1:1739 S 90TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-3121
Mailing Address - Country:US
Mailing Address - Phone:253-592-4941
Mailing Address - Fax:
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:620
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1720
Practice Address - Country:US
Practice Address - Phone:206-343-3325
Practice Address - Fax:206-838-7330
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60524204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist