Provider Demographics
NPI:1689988123
Name:STARR, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:STARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10324 CANYON RD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1013
Mailing Address - Country:US
Mailing Address - Phone:253-537-6000
Mailing Address - Fax:
Practice Address - Street 1:10324 CANYON RD E
Practice Address - Street 2:105
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1013
Practice Address - Country:US
Practice Address - Phone:253-537-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist