Provider Demographics
NPI:1861770778
Name:FAIX, JONATHAN CHARLES (LAC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:CHARLES
Last Name:FAIX
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1053
Mailing Address - Country:US
Mailing Address - Phone:509-488-0797
Mailing Address - Fax:
Practice Address - Street 1:225 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1053
Practice Address - Country:US
Practice Address - Phone:509-488-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60218566171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist