Provider Demographics
NPI:1609416478
Name:JORGENSEN, KYLE (LMT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:JORGENSEN
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 1:1256 SE BISHOP BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5414
Mailing Address - Country:US
Mailing Address - Phone:509-332-6506
Mailing Address - Fax:
Practice Address - Street 1:1256 SE BISHOP BLVD STE J
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5414
Practice Address - Country:US
Practice Address - Phone:509-332-6506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61031942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist