Basic Information
| Provider Information | |||||||||
| NPI: | 1992875314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPT, OCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHATTUCK | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 510 8TH AVE NE STE 320 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253133051 | ||||||||
| FaxNumber: | 4256253517 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 8TH AVE NE STE 340 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253133051 | ||||||||
| FaxNumber: | 4253133055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00009591 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | PT00009591 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | PT00009591 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 1024073 | 05 | WA | MEDICAID |