Provider Demographics
NPI:1487079497
Name:SAMPLES, JEREMIAH (LMP)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:SAMPLES
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2333
Mailing Address - Country:US
Mailing Address - Phone:425-268-2800
Mailing Address - Fax:
Practice Address - Street 1:2215 LOMBARD AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2333
Practice Address - Country:US
Practice Address - Phone:425-268-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60414440225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist