Provider Demographics
NPI:1649560145
Name:JACK, MARLAYNA LOY (LMP)
Entity Type:Individual
Prefix:
First Name:MARLAYNA
Middle Name:LOY
Last Name:JACK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 185TH CT NE APT Y204
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-5054
Mailing Address - Country:US
Mailing Address - Phone:206-334-9848
Mailing Address - Fax:
Practice Address - Street 1:10827 NE 68TH ST
Practice Address - Street 2:STE E
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-4000
Practice Address - Country:US
Practice Address - Phone:206-334-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60205627225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist