Provider Demographics
NPI:1689091340
Name:DEIDERS, JADE (LMP)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:DEIDERS
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 1:2482 HIGHWAY 141
Mailing Address - Street 2:
Mailing Address - City:TROUT LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98650-9703
Mailing Address - Country:US
Mailing Address - Phone:541-490-2933
Mailing Address - Fax:
Practice Address - Street 1:302 W STEUBEN ST
Practice Address - Street 2:#7
Practice Address - City:BINGEN
Practice Address - State:WA
Practice Address - Zip Code:98605-0834
Practice Address - Country:US
Practice Address - Phone:541-490-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022112225700000X
OR12874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist