Provider Demographics
NPI:1083982359
Name:RALSTON, JESSICA TAYLOR (LMP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:TAYLOR
Last Name:RALSTON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6808 220TH ST SW
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2187
Mailing Address - Country:US
Mailing Address - Phone:425-776-1056
Mailing Address - Fax:425-776-1056
Practice Address - Street 1:6808 220TH ST SW
Practice Address - Street 2:SUITE 203
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2187
Practice Address - Country:US
Practice Address - Phone:425-776-1056
Practice Address - Fax:425-776-1056
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60255499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist