Provider Demographics
NPI:1730587114
Name:BAUMGARTNER, JESSICA SUE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6681 SYCAMORE LN
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1212
Mailing Address - Country:US
Mailing Address - Phone:901-596-0862
Mailing Address - Fax:
Practice Address - Street 1:105 N TACOMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-2631
Practice Address - Country:US
Practice Address - Phone:901-596-0862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60498326225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist