Basic Information
| Provider Information | |||||||||
| NPI: | 1457623290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRONSIDE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4040 ORCHARD ST W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FIRCREST | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984666606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535641560 | ||||||||
| FaxNumber: | 2535644449 | ||||||||
| Practice Location | |||||||||
| Address1: | 7308 BRIDGEPORT WAY W | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984998000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535828142 | ||||||||
| FaxNumber: | 2535828160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2012 | ||||||||
| LastUpdateDate: | 11/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60252447 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.