1114059615 NPI number — OTEKA E JENKINS LMP

Table of content: OTEKA E JENKINS LMP (NPI 1114059615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114059615 NPI number — OTEKA E JENKINS LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
OTEKA
Provider Middle Name:
E
Provider Name Prefix Text:
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:
1114059615
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:
3627 WHEATON WAY
Provider Second Line Business Mailing Address:
STE 105A
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98310-3545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-377-3601
Provider Business Mailing Address Fax Number:
360-373-9494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 WHEATON WAY
Provider Second Line Business Practice Location Address:
STE 105A
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310-3545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-377-3601
Provider Business Practice Location Address Fax Number:
360-373-9494
Provider Enumeration Date:
03/10/2007

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: 225700000X , with the licence number:  MA00015056 , 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: 0156398 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 91-211509104 . This is a "KPS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MA00015056 . This is a "STATE MASSAGE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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