MEDICARE: JACQUELINE SOPHIA LOTT 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	174400000X	Specialist	MA00017942	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA00017942	OTHER	WA	MASSAGE THERPIST LICENSE

General Provider Information

NPI Number	:	1144351925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE SOPHIA LOTT LMP

Provider Business Mailing Address
First Line	:	1008 S 40TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98908-3804
Country	:	US
Telephone Number	:	509-972-4000
Fax Number	:	509-972-4001

Provider Business Practice Location Address
First Line	:	1008 S 40TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98908-3804
Country	:	US
Telephone Number	:	509-972-4000
Fax Number	:	509-972-4001

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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