Provider Demographics
NPI:1194926444
Name:JENKINS, LACIE IRENE (LMP)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:IRENE
Last Name:JENKINS
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:PO BOX 1194
Mailing Address - Street 2:
Mailing Address - City:COSMOPOLIS
Mailing Address - State:WA
Mailing Address - Zip Code:98537
Mailing Address - Country:US
Mailing Address - Phone:360-580-2845
Mailing Address - Fax:
Practice Address - Street 1:513 E STREET
Practice Address - Street 2:
Practice Address - City:COSMOPOLIS
Practice Address - State:WA
Practice Address - Zip Code:98537
Practice Address - Country:US
Practice Address - Phone:360-580-2845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist