MEDICARE: JACOB J BRONOWSKI 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	MA60738064	WA

General Provider Information

NPI Number	:	1972011641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB J BRONOWSKI LMP

Provider Business Mailing Address
First Line	:	2415 2ND AVE APT 537
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98121-1432
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14800 STARFIRE WAY
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98188-8502
Country	:	US
Telephone Number	:	206-989-9732
Fax Number	:

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

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	03/17/2018

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