Provider Demographics
NPI:1497393722
Name:GRANSTROM, JARRED DUSTIN (LMT)
Entity Type:Individual
Prefix:
First Name:JARRED
Middle Name:DUSTIN
Last Name:GRANSTROM
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 1:1903 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1031
Mailing Address - Country:US
Mailing Address - Phone:360-865-8548
Mailing Address - Fax:
Practice Address - Street 1:160 ROY ST # 4162
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4162
Practice Address - Country:US
Practice Address - Phone:206-453-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60929512225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist