Provider Demographics
NPI:1760761241
Name:SALAS, JACKLIEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JACKLIEN
Middle Name:
Last Name:SALAS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20930 108TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-1101
Mailing Address - Country:US
Mailing Address - Phone:253-856-8868
Mailing Address - Fax:
Practice Address - Street 1:20930 108TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-1101
Practice Address - Country:US
Practice Address - Phone:253-856-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60233338174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist