Provider Demographics
NPI:1548836323
Name:LUSK, JACQUELINE FAE (LMT)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:FAE
Last Name:LUSK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 CALIFORNIA AVE SW #4
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116
Mailing Address - Country:US
Mailing Address - Phone:206-377-9664
Mailing Address - Fax:
Practice Address - Street 1:15858 1ST AVE S.
Practice Address - Street 2:STE 104
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148
Practice Address - Country:US
Practice Address - Phone:206-838-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60769558225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist