Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | OT00003450 | WA |
NPI | 1003022674 |
---|---|
Provider Name | Jaclyn Ann Subkoviak |
First Address | Seattle, WA 98101-2756 |
Second Address | Seattle, WA 98101-2756 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2007 |
Last Update Date | 18/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0039622 | LABOR AND INDUSTRIES# (01) | WA |
8341489 | (05) | WA |
Q40100 | (02) |