Provider Demographics
NPI:1649877481
Name:DJAJAPUTRA, JAHJA (LMT)
Entity type:Individual
Prefix:MR
First Name:JAHJA
Middle Name:
Last Name:DJAJAPUTRA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11030 EVERGREEN WAY APT E123
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-6655
Mailing Address - Country:US
Mailing Address - Phone:206-412-6179
Mailing Address - Fax:
Practice Address - Street 1:9633 MARKET PL UNIT 103
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-7944
Practice Address - Country:US
Practice Address - Phone:425-335-0300
Practice Address - Fax:425-335-0302
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61098412225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA61098412OtherLMT