Provider Demographics
NPI:1760842272
Name:VAN DOUGHTY, JAIME MARISA (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:MARISA
Last Name:VAN DOUGHTY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:JAIME
Other - Middle Name:MARISA
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:1015 SW 150TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1831
Mailing Address - Country:US
Mailing Address - Phone:206-409-8723
Mailing Address - Fax:
Practice Address - Street 1:1015 SW 150TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1831
Practice Address - Country:US
Practice Address - Phone:206-409-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist