Provider Demographics
NPI:1679971568
Name:SMITH, JALENE (LMP)
Entity Type:Individual
Prefix:
First Name:JALENE
Middle Name:
Last Name:SMITH
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 1:8942 COLONY LN SE
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2530 NE KRESKY AVE STE B
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2406
Practice Address - Country:US
Practice Address - Phone:360-996-4778
Practice Address - Fax:360-996-4783
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0162228OtherDEPARTMENT OF LABOR AND INDUSTRIES