Healthcare Provider Details

I. General information

NPI: 1285759241
Provider Name (Legal Business Name): PENNY JO BROOKS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43817 SE 149TH ST
NORTH BEND WA
98045
US

IV. Provider business mailing address

43817 SE 149TH ST
NORTH BEND WA
98045
US

V. Phone/Fax

Practice location:
  • Phone: 425-888-8710
  • Fax: 425-888-4763
Mailing address:
  • Phone: 425-888-8710
  • Fax: 425-888-4763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00011709
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: