1780885392 NPI number — MS. JACKI L STRADER LMP

Table of content: MS. JACKI L STRADER LMP (NPI 1780885392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780885392 NPI number — MS. JACKI L STRADER LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STRADER
Provider First Name:
JACKI
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780885392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98354-0911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-530-7819
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 RAINIER AVENUE SOUTH
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EATONVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98328-0546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-832-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MA00009325 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109448 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 5586ST . This is a "REGENCE PROVIDER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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