Healthcare Provider Details

I. General information

NPI: 1255649869
Provider Name (Legal Business Name): JAMES KIMO JANDOC OMT, LMT, STMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 GROVER ST STE C3
LYNDEN WA
98264
US

IV. Provider business mailing address

1610 GROVER ST STE C3
LYNDEN WA
98264-1539
US

V. Phone/Fax

Practice location:
  • Phone: 360-510-4630
  • Fax: 360-935-9731
Mailing address:
  • Phone: 360-510-4630
  • Fax: 360-935-9731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMA00015681
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00015681
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: