Provider Demographics
NPI:1467756759
Name:WIENCKOSKI, JORDEN DANIEL (LMP)
Entity Type:Individual
Prefix:MR
First Name:JORDEN
Middle Name:DANIEL
Last Name:WIENCKOSKI
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S DATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-5755
Mailing Address - Country:US
Mailing Address - Phone:509-222-0925
Mailing Address - Fax:
Practice Address - Street 1:7514 W YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1101
Practice Address - Country:US
Practice Address - Phone:509-783-7242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-31
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60137771225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist