Provider Demographics
NPI:1598733537
Name:FRADY, JACQUELINE A (LMP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:A
Last Name:FRADY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:FRADY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:6420 195TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8858
Mailing Address - Country:US
Mailing Address - Phone:253-209-2137
Mailing Address - Fax:
Practice Address - Street 1:603 HUNT AVE STE B
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1117
Practice Address - Country:US
Practice Address - Phone:253-209-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2014-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist