Provider Demographics
NPI:1710362967
Name:FREE, JESSE LEE (MA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LEE
Last Name:FREE
Suffix:
Gender:M
Credentials:MA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7335
Mailing Address - Country:US
Mailing Address - Phone:425-512-2704
Mailing Address - Fax:
Practice Address - Street 1:737 LOGAN AVE NORTH
Practice Address - Street 2:MC 9C-01
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-0000
Practice Address - Country:US
Practice Address - Phone:425-512-2704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1604831052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer