Provider Demographics
NPI:1619166451
Name:TISSELL, JEFF (LMP)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:TISSELL
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 1:18606 10TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9621
Mailing Address - Country:US
Mailing Address - Phone:425-830-9509
Mailing Address - Fax:
Practice Address - Street 1:18008 BOTHELL EVERETT HWY
Practice Address - Street 2:UNIT F
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-6842
Practice Address - Country:US
Practice Address - Phone:425-830-9509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005339225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist