Provider Demographics
NPI:1386208999
Name:KONGSLIE, JESSICA NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:KONGSLIE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 BROOKMONTE DR SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-5173
Mailing Address - Country:US
Mailing Address - Phone:253-678-9393
Mailing Address - Fax:
Practice Address - Street 1:2015 BROOKMONTE DR SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-5173
Practice Address - Country:US
Practice Address - Phone:253-682-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023679225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist