Provider Demographics
NPI:1740502764
Name:WACHAL, JACKLYN M (LMP)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:M
Last Name:WACHAL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:M
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:129 176TH ST S STE A
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-4616
Mailing Address - Country:US
Mailing Address - Phone:253-539-0132
Mailing Address - Fax:253-539-0241
Practice Address - Street 1:129 176TH ST S STE A
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-4616
Practice Address - Country:US
Practice Address - Phone:253-539-0132
Practice Address - Fax:253-539-0241
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60124562225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist