Provider Demographics
NPI:1104587955
Name:MCCAULEY, JESTYNE MAE (LMT)
Entity type:Individual
Prefix:
First Name:JESTYNE
Middle Name:MAE
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JESTYNE
Other - Middle Name:MAE
Other - Last Name:FRIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8221 NE HAZEL DELL AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8153
Mailing Address - Country:US
Mailing Address - Phone:360-334-6373
Mailing Address - Fax:360-583-3559
Practice Address - Street 1:8221 NE HAZEL DELL AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8153
Practice Address - Country:US
Practice Address - Phone:360-334-6373
Practice Address - Fax:360-583-3559
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61254488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist