Provider Demographics
NPI:1871782797
Name:STOCKMAN, JEANIE (LMP)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:STOCKMAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2514
Mailing Address - Country:US
Mailing Address - Phone:509-200-0551
Mailing Address - Fax:
Practice Address - Street 1:2316 EASTGATE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2554
Practice Address - Country:US
Practice Address - Phone:509-200-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015759225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist