Provider Demographics
NPI:1861553109
Name:DAMBROSIO, JEFFERY JOHN (LMP)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:JOHN
Last Name:DAMBROSIO
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 EASTLAKE AVE E APT 604
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3755
Mailing Address - Country:US
Mailing Address - Phone:206-856-4005
Mailing Address - Fax:
Practice Address - Street 1:4020 LEARY WAY NW
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5002
Practice Address - Country:US
Practice Address - Phone:206-856-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022159225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist