Provider Demographics
NPI:1043757453
Name:HYDE, JEREMY EDWARD (LMP)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:EDWARD
Last Name:HYDE
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 1:13775 INTERURBAN AVE S
Mailing Address - Street 2:APT. D102
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-5104
Mailing Address - Country:US
Mailing Address - Phone:207-602-9973
Mailing Address - Fax:
Practice Address - Street 1:24837 104TH AVE SE
Practice Address - Street 2:STE 100
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6800
Practice Address - Country:US
Practice Address - Phone:253-854-7700
Practice Address - Fax:253-854-2986
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60647795225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist