Provider Demographics
NPI:1609213560
Name:OMURA, JACLYN CHRISTINE (MD)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:CHRISTINE
Last Name:OMURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JACLYN
Other - Middle Name:CHRISTINE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5371
Mailing Address - Street 2:OD 8 410
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-987-2850
Mailing Address - Fax:206-987-2651
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605842572081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Single Specialty