Provider Demographics
NPI:1730238528
Name:SUNDAHL, JESSICA D (LMP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:D
Last Name:SUNDAHL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:D
Other - Last Name:TISCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:4815 97TH ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-5428
Mailing Address - Country:US
Mailing Address - Phone:253-905-5214
Mailing Address - Fax:253-503-6146
Practice Address - Street 1:4111 S MERIDIAN
Practice Address - Street 2:SUITE 208
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5973
Practice Address - Country:US
Practice Address - Phone:253-905-5214
Practice Address - Fax:253-503-6146
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016460225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0158989OtherLABOR AND INDUSTRIES
WA6021925760010001OtherUBI BUSINESS
WAMA00016460OtherLICENSE FOR MASSAGE
WA4342TIOtherREGENCECARE ID NUMBER
WA254423100000OtherPREMERA PROVIDER NUMBER
WA0007827360OtherAETNA PROVIDER NUMBER
WA0007827360OtherAETNA PROVIDER NUMBER