Provider Demographics
NPI:1700861804
Name:TAKAESU, JEAN M (OTR/L)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:TAKAESU
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 NE 137TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-4933
Mailing Address - Country:US
Mailing Address - Phone:360-944-4988
Mailing Address - Fax:
Practice Address - Street 1:7101 NE 137TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-4933
Practice Address - Country:US
Practice Address - Phone:360-944-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003054225XH1200X
OR1031035225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098565024OtherBCBSO
WA0199636OtherWA L&I
WA8434631Medicaid
OR269899Medicaid
OR132530Medicare ID - Type Unspecified