Provider Demographics
NPI:1720387525
Name:THOR, JESSICA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:THOR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:19102 STATE ROUTE 410 E. #A
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391
Mailing Address - Country:US
Mailing Address - Phone:253-863-6378
Mailing Address - Fax:
Practice Address - Street 1:19102 STATE ROUTE 410 E STE A
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8449
Practice Address - Country:US
Practice Address - Phone:253-863-6378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019936174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist