Provider Demographics
NPI:1700432671
Name:HARDY, JAMIE LYNN (CBTCB60986081)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:HARDY
Suffix:
Gender:F
Credentials:CBTCB60986081
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WATSON ST N APT D5
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-7317
Mailing Address - Country:US
Mailing Address - Phone:208-982-7114
Mailing Address - Fax:
Practice Address - Street 1:750 WATSON ST N APT D5
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-7317
Practice Address - Country:US
Practice Address - Phone:208-982-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACBT.CB.60986081156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty