Healthcare Provider Details

I. General information

NPI: 1104037860
Provider Name (Legal Business Name): JOLEEN DENISE BLACK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8827 31ST AVE SW # 1
SEATTLE WA
98126-3718
US

IV. Provider business mailing address

8827 31ST AVE SW
SEATTLE WA
98126-3718
US

V. Phone/Fax

Practice location:
  • Phone: 206-841-4031
  • Fax: 206-973-2747
Mailing address:
  • Phone: 206-841-4031
  • Fax: 206-973-2747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60530881
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00020122
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: