MEDICARE: JOLENE O'CONNELL 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	MA00017297	WA

General Provider Information

NPI Number	:	1336211622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLENE O'CONNELL LMP

Provider Business Mailing Address
First Line	:	6210 75TH ST W
Second Line	:	SUITE A100
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8303
Country	:	US
Telephone Number	:	253-588-1800
Fax Number	:	253-588-8781

Provider Business Practice Location Address
First Line	:	6210 75TH ST W
Second Line	:	SUITE A100
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8303
Country	:	US
Telephone Number	:	253-588-1800
Fax Number	:	253-588-8781

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/16/2012

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