Healthcare Provider Details

I. General information

NPI: 1306908819
Provider Name (Legal Business Name): BENITA A JANGALA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16761 NE 79TH ST
REDMOND WA
98052-4425
US

IV. Provider business mailing address

PO BOX 11009
OLYMPIA WA
98508-1009
US

V. Phone/Fax

Practice location:
  • Phone: 206-799-1187
  • Fax: 425-869-7691
Mailing address:
  • Phone: 360-352-2037
  • Fax: 360-352-0637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: