Provider Demographics
NPI:1447745468
Name:CHILDERS, JESSE DAVID (LMT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVID
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 BELLEVUE AVE E APT 4
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-6830
Mailing Address - Country:US
Mailing Address - Phone:206-420-9378
Mailing Address - Fax:
Practice Address - Street 1:509 OLIVE WAY STE 1407
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1746
Practice Address - Country:US
Practice Address - Phone:206-853-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60854058225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist