Provider Demographics
NPI:1306345350
Name:OMARA, JEANNIE (LMT)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:OMARA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18927 33RD AVE W STE B
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4726
Mailing Address - Country:US
Mailing Address - Phone:425-776-1177
Mailing Address - Fax:425-776-5533
Practice Address - Street 1:18927 33RD AVE W STE B
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4726
Practice Address - Country:US
Practice Address - Phone:425-776-1177
Practice Address - Fax:425-776-5533
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60711980225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60711980OtherSTATE MASSAGE LICENSE