1275691859 NPI number — MRS. JULIE MARIE JACKA LMP

Table of content: MRS. JULIE MARIE JACKA LMP (NPI 1275691859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275691859 NPI number — MRS. JULIE MARIE JACKA LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKA
Provider First Name:
JULIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
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:
GOUGH
Provider Other First Name:
JULIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275691859
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:
14 W GRAVES
Provider Second Line Business Mailing Address:
LOWER LEVEL
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-466-6106
Provider Business Mailing Address Fax Number:
509-466-2925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 W GRAVES
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-466-6106
Provider Business Practice Location Address Fax Number:
509-466-2925
Provider Enumeration Date:
12/05/2006

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:  MA12489 , 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)