Provider Demographics
NPI:1306169842
Name:JONES, KYLE STEALY (LMP)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:STEALY
Last Name:JONES
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 WHITMAN LN SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-2201
Mailing Address - Country:US
Mailing Address - Phone:360-923-1717
Mailing Address - Fax:360-923-0404
Practice Address - Street 1:4631 WHITMAN LN SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98513-2201
Practice Address - Country:US
Practice Address - Phone:360-923-1717
Practice Address - Fax:360-923-0404
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60129855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA202640271OtherD.C.
WA539928826OtherD.C.