Provider Demographics
NPI:1609890029
Name:DIRKSEN PHYSICAL THERAPY INC PS
Entity Type:Organization
Organization Name:DIRKSEN PHYSICAL THERAPY INC PS
Other - Org Name:DIRKSEN PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-385-9310
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339-0897
Mailing Address - Country:US
Mailing Address - Phone:360-385-9310
Mailing Address - Fax:360-379-8826
Practice Address - Street 1:27 COLWELL STREET
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339
Practice Address - Country:US
Practice Address - Phone:360-385-9310
Practice Address - Fax:360-379-8826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7087661Medicaid
WA7087661Medicaid