Provider Demographics
NPI:1679948293
Name:BALLARD, JACK (LMP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BALLARD
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 1:10513 SILVERDALE WAY SUITE 101
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383
Mailing Address - Country:US
Mailing Address - Phone:360-698-4411
Mailing Address - Fax:
Practice Address - Street 1:10513 SILVERDALE WAY NW STE 101
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9499
Practice Address - Country:US
Practice Address - Phone:360-698-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60473288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist