Provider Demographics
NPI:1487140513
Name:WANGLER, JACOB CODY (LMT # MA60869105)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:CODY
Last Name:WANGLER
Suffix:
Gender:M
Credentials:LMT # MA60869105
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1111 W SPRUCE ST STE 25
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3260
Mailing Address - Country:US
Mailing Address - Phone:509-452-5155
Mailing Address - Fax:509-452-5355
Practice Address - Street 1:1111 W SPRUCE ST STE 25
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3260
Practice Address - Country:US
Practice Address - Phone:509-452-5155
Practice Address - Fax:509-452-5355
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60869105225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist