Basic Information
| Provider Information | |||||||||
| NPI: | 1750681359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENSIGN | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4320 196TH ST SW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980366773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259670051 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4320 196TH ST SW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980366773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259670051 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2010 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | P160033940 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.