Provider Demographics
NPI:1760523880
Name:SMITH, JOLENE ROSE (LMP)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:ROSE
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 1:1710 19TH DR NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-3467
Mailing Address - Country:US
Mailing Address - Phone:206-235-3689
Mailing Address - Fax:
Practice Address - Street 1:1710 19TH DR NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-3467
Practice Address - Country:US
Practice Address - Phone:206-235-3689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018366225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAL7171549OtherAETNA HEALTHCARE
WA0190441OtherLABOR AND INDUSTRIES