Individual
JACKIE MARIE BENNETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMP, CLT
Contact information
Practice address
10508 123RD STREET CT E, PUYALLUP, WA 98374-2626
(253) 209-6276
Mailing address
10508 123RD STREET CT E, PUYALLUP, WA 98374-2626
(253) 209-6276
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA00022947
WA
Other
Enumeration date
05/18/2011
Last updated
05/18/2011
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