Provider Demographics
NPI:1780885392
Name:STRADER, JACKI L (LMP)
Entity type:Individual
Prefix:MS
First Name:JACKI
Middle Name:L
Last Name:STRADER
Suffix:
Gender:F
Credentials:LMP
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 911
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-0911
Mailing Address - Country:US
Mailing Address - Phone:253-530-7819
Mailing Address - Fax:
Practice Address - Street 1:109 RAINIER AVENUE SOUTH
Practice Address - Street 2:SUITE C
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328-0546
Practice Address - Country:US
Practice Address - Phone:360-832-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA109448OtherSTATE L&I
WA5586STOtherREGENCE PROVIDER