Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA00015110 | WA |
NPI | 1013555846 |
---|---|
Provider Name | Jim Locklear |
First Address | Burien, WA 98166-2701 |
Second Address | Burien, WA 98166-2213 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2019 |
Last Update Date | 11/12/2019 |