MEDICARE: MRS. JOLEEN MICHELLE BACON LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00011700	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	146955	OTHER	WA	LABOR AND INDUSTRIES
2	8405BA	OTHER	WA	REGENCE

General Provider Information

NPI Number	:	1174678098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOLEEN MICHELLE BACON LMP

Provider Business Mailing Address
First Line	:	4620 200TH ST SW
Second Line	:	SUITE C
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-6607
Country	:	US
Telephone Number	:	425-697-5144
Fax Number	:	425-778-0824

Provider Business Practice Location Address
First Line	:	4620 200TH ST SW
Second Line	:	SUITE C
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-6607
Country	:	US
Telephone Number	:	425-697-5144
Fax Number	:	425-778-0824

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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