Healthcare Provider Details

I. General information

NPI: 1235459348
Provider Name (Legal Business Name): SALLY JO DONOHUE CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY JO LONG (MAIDEN)

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 SO UNION AVE #2-C
TACOMA WA
98405-1953
US

IV. Provider business mailing address

1818 SO UNION AVE #2-C
TACOMA WA
98405-1953
US

V. Phone/Fax

Practice location:
  • Phone: 253-627-7567
  • Fax: 253-627-4778
Mailing address:
  • Phone: 253-627-7567
  • Fax: 253-627-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberLD00001723
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: