Provider Demographics
NPI:1124643796
Name:ROMAN, JAYLEEN NICHOLE (MA 00020615)
Entity type:Individual
Prefix:
First Name:JAYLEEN
Middle Name:NICHOLE
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MA 00020615
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 99TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-8988
Mailing Address - Country:US
Mailing Address - Phone:360-540-9777
Mailing Address - Fax:
Practice Address - Street 1:8229 44TH AVE W STE F
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-2849
Practice Address - Country:US
Practice Address - Phone:425-381-3866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist