Provider Demographics
NPI:1083784482
Name:NIEDZINSKI, JEFFREY (MPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:NIEDZINSKI
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:3912 10TH ST SE
Practice Address - Street 2:SUITE 101
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2188
Practice Address - Country:US
Practice Address - Phone:253-848-4700
Practice Address - Fax:253-848-2284
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA194291OtherDEPT OF LABOR & INDUSTRY
WA8554NIOtherREGENCE BLUE SHIELD
WA8416075Medicaid
WA8851151OtherPIERCE COUNTY
WA8939972OtherCRIME VICTIMS
WA8851151OtherPIERCE COUNTY
WA8851152Medicare ID - Type UnspecifiedKING COUNTY