Provider Demographics
NPI:1578983409
Name:WIESE, JENNIFER (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5829 S WARNER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-4221
Mailing Address - Country:US
Mailing Address - Phone:602-320-5203
Mailing Address - Fax:
Practice Address - Street 1:5829 S WARNER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4221
Practice Address - Country:US
Practice Address - Phone:602-320-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60430563225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist