1497936546 NPI number — MRS. JACLYN JUNE MONGE SOUTHARD LMT

Table of content: MRS. JACLYN JUNE MONGE SOUTHARD LMT (NPI 1497936546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497936546 NPI number — MRS. JACLYN JUNE MONGE SOUTHARD LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHARD
Provider First Name:
JACLYN
Provider Middle Name:
JUNE MONGE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
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:
1497936546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9649 LOOKOUT DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98502-9757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-388-0485
Provider Business Mailing Address Fax Number:
360-890-4066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4520 INTELCO LOOP SE BLDG 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98503-6008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-388-0485
Provider Business Practice Location Address Fax Number:
360-890-4066
Provider Enumeration Date:
11/16/2007

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: 172M00000X , with the licence number:  MA00023326 , 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)





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