Provider Demographics
NPI:1821502485
Name:HAFERKORN, JOLENE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:MARIE
Last Name:HAFERKORN
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 1:506 GROVER ST STE 111
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1960
Mailing Address - Country:US
Mailing Address - Phone:425-236-9088
Mailing Address - Fax:
Practice Address - Street 1:506 GROVER ST STE 111
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1960
Practice Address - Country:US
Practice Address - Phone:425-236-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60788136225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60788136OtherWASHINGTON STATE DEPARTMENT OF HEALTH