=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700171683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNINE GRAF JONSSON LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2011
-----------------------------------------------------
Last Update Date | 05/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3343 NW BYRON ST
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-9123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-692-8920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 EAGLEVIEW LN
-----------------------------------------------------
City | PORT LUDLOW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98365-9519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-437-6911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA60230458
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------