Provider Demographics
NPI:1639303068
Name:FAIRCHILD, JONATHAN MICHEAL (LMP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHEAL
Last Name:FAIRCHILD
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 1:3214 45TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-2814
Mailing Address - Country:US
Mailing Address - Phone:253-927-2897
Mailing Address - Fax:
Practice Address - Street 1:3214 45TH AVE NE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98422-2814
Practice Address - Country:US
Practice Address - Phone:253-927-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60080892225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist