Healthcare Provider Details

I. General information

NPI: 1972217347
Provider Name (Legal Business Name): JAYMIE MICHELLE MARLOW CB61368481
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DICE EIRA MARLOW CB61368481

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 S PINE ST STE 505
TACOMA WA
98409-7208
US

IV. Provider business mailing address

5870 BRASCH RD SE
PORT ORCHARD WA
98367-1119
US

V. Phone/Fax

Practice location:
  • Phone: 253-671-9909
  • Fax:
Mailing address:
  • Phone: 737-242-6662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61368481
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: