1679971568 NPI number — JALENE SMITH LMP

Table of content: ROSALYCE LUCILE ROSE RDH (NPI 1083029078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679971568 NPI number — JALENE SMITH LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JALENE
Provider Middle Name:
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:
1679971568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8942 COLONY LN SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TENINO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98589-9426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2530 NE KRESKY AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEHALIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98532-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-996-4778
Provider Business Practice Location Address Fax Number:
360-996-4783
Provider Enumeration Date:
12/09/2014

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:  MA00015967 , 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: 0162228 . This is a "DEPARTMENT OF LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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