Provider Demographics
NPI:1124230180
Name:JORDAN, BONNIE JEAN (LMP)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:JORDAN
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 1:1420 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2607
Mailing Address - Country:US
Mailing Address - Phone:509-326-9107
Mailing Address - Fax:
Practice Address - Street 1:1420 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2607
Practice Address - Country:US
Practice Address - Phone:509-326-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006150225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist