Provider Demographics
NPI:1174678098
Name:BACON, JOLEEN MICHELLE (LMP)
Entity type:Individual
Prefix:MRS
First Name:JOLEEN
Middle Name:MICHELLE
Last Name:BACON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 200TH ST SW
Mailing Address - Street 2:SUITE C
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6607
Mailing Address - Country:US
Mailing Address - Phone:425-697-5144
Mailing Address - Fax:425-778-0824
Practice Address - Street 1:4620 200TH ST SW
Practice Address - Street 2:SUITE C
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6607
Practice Address - Country:US
Practice Address - Phone:425-697-5144
Practice Address - Fax:425-778-0824
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA146955OtherLABOR AND INDUSTRIES
WA8405BAOtherREGENCE