Provider Demographics
NPI:1619738804
Name:SIDES, JEBEDIAH I (LMT)
Entity type:Individual
Prefix:
First Name:JEBEDIAH
Middle Name:I
Last Name:SIDES
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 NE 115TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-4479
Mailing Address - Country:US
Mailing Address - Phone:360-949-0133
Mailing Address - Fax:360-768-5110
Practice Address - Street 1:14010 NE 3RD CT BLDG B
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2928
Practice Address - Country:US
Practice Address - Phone:360-949-0133
Practice Address - Fax:360-768-5110
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61512969225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist