Provider Demographics
NPI:1497936546
Name:SOUTHARD, JACLYN JUNE MONGE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:JUNE MONGE
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9649 LOOKOUT DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9757
Mailing Address - Country:US
Mailing Address - Phone:360-388-0485
Mailing Address - Fax:360-890-4066
Practice Address - Street 1:4520 INTELCO LOOP SE BLDG 3
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6008
Practice Address - Country:US
Practice Address - Phone:360-388-0485
Practice Address - Fax:360-890-4066
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023326172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist