Provider Demographics
NPI:1184230716
Name:TAKAGI, JOHN BENJAMIN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BENJAMIN
Last Name:TAKAGI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7509 TRADITIONS AVE NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-1336
Mailing Address - Country:US
Mailing Address - Phone:208-703-8154
Mailing Address - Fax:
Practice Address - Street 1:901 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4401
Practice Address - Country:US
Practice Address - Phone:360-427-9545
Practice Address - Fax:360-427-3616
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60587662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist