=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831323344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACI WIXOM JACOBS LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2009
-----------------------------------------------------
Last Update Date | 05/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1235 N LIBERTY LAKE RD SUITE 106
-----------------------------------------------------
City | LIBERTY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99019-7581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-434-9959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20610 E 1ST AVE
-----------------------------------------------------
City | GREENACRES
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99016-9659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-434-9959
-----------------------------------------------------
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 | MA 00025318
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------