Provider Demographics
NPI:1386000115
Name:ELLINGER, JAMIL (LMP)
Entity type:Individual
Prefix:
First Name:JAMIL
Middle Name:
Last Name:ELLINGER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:EMRY
Other - Middle Name:
Other - Last Name:ELLINGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8830 TALLON LN NE
Mailing Address - Street 2:STE F
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6656
Mailing Address - Country:US
Mailing Address - Phone:360-819-2877
Mailing Address - Fax:
Practice Address - Street 1:8830 TALLON LN NE
Practice Address - Street 2:STE F
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6656
Practice Address - Country:US
Practice Address - Phone:360-819-2877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60483747225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist