Basic Information
| Provider Information | |||||||||
| NPI: | 1508411489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLER | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | CLAYTON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 DENNIS ST SW STE B | ||||||||
| Address2: | |||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985016523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603380181 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12410 E SINTO AVE STE 205 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992162280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099225156 | ||||||||
| FaxNumber: | 5098933962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT014147 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.