Provider Demographics
NPI:1538856240
Name:BRACKIN, TESSA LEIGH (LMP)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:LEIGH
Last Name:BRACKIN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-8723
Mailing Address - Country:US
Mailing Address - Phone:360-302-0998
Mailing Address - Fax:
Practice Address - Street 1:3312 ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1804
Practice Address - Country:US
Practice Address - Phone:253-549-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61327410225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist