Healthcare Provider Details

I. General information

NPI: 1376770446
Provider Name (Legal Business Name): JEREMY STARR SYKES LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16414 17TH AVE E
SPANAWAY WA
98387-7638
US

IV. Provider business mailing address

16414 17TH AVE E
SPANAWAY WA
98387-7638
US

V. Phone/Fax

Practice location:
  • Phone: 253-439-9972
  • Fax:
Mailing address:
  • Phone: 253-439-9972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60080880
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: