Healthcare Provider Details

I. General information

NPI: 1700432671
Provider Name (Legal Business Name): JAMIE LYNN HARDY CBT.CB.60986081
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WATSON ST N APT D5
ENUMCLAW WA
98022-7317
US

IV. Provider business mailing address

750 WATSON ST N APT D5
ENUMCLAW WA
98022-7317
US

V. Phone/Fax

Practice location:
  • Phone: 208-982-7114
  • Fax:
Mailing address:
  • Phone: 208-982-7114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberCBT.CB.60986081
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: