MEDICARE: JAY RUSSELL JEFFRIES LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA0008469	WA

General Provider Information

NPI Number	:	1134521016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY RUSSELL JEFFRIES LMP

Provider Business Mailing Address
First Line	:	2229 EVERGREEN POINT RD
Second Line	:
City	:	MEDINA
State	:	WA
Zip	:	98039-2342
Country	:	US
Telephone Number	:	808-561-1710
Fax Number	:	206-299-3436

Provider Business Practice Location Address
First Line	:	2229 EVERGREEN POINT RD
Second Line	:
City	:	MEDINA
State	:	WA
Zip	:	98039-2342
Country	:	US
Telephone Number	:	808-561-1710
Fax Number	:	206-299-3436

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2014
Last Update Date	:	09/22/2014

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