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General NPI Number Information
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NPI Number | 1417525924
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Entity Type | Individual
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Provider Name | JEFFERY B WANG LMT
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Gender | Male
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Dates
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Enumeration Date | 06/12/2021
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Last Update Date | 07/15/2021
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Provider Practice Location Address
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Address Line | 4525 3RD AVE SE STE 200
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City | LACEY
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State | WA
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Zip | 98503-1010
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Country | US
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Telephone | 503-360-8989
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Fax |
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Provider Business Mailing Address
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Address Line | 1708 10TH AVE SE
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City | OLYMPIA
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State | WA
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Zip | 98501-1817
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Country | US
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Telephone | 503-360-8989
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA61158410
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License Number State | WA
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