Provider Demographics
NPI:1790077014
Name:MUSTARD, JOVONNE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:JOVONNE
Middle Name:
Last Name:MUSTARD
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:VAUGHN
Mailing Address - State:WA
Mailing Address - Zip Code:98394-0481
Mailing Address - Country:US
Mailing Address - Phone:360-551-7606
Mailing Address - Fax:
Practice Address - Street 1:9414 RIDGETOP BLVD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8525
Practice Address - Country:US
Practice Address - Phone:360-551-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60215824225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist