Provider Demographics
NPI:1750681359
Name:PATRICK, JESSICA SUE (LPTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUE
Other - Last Name:ENSIGN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:4320 196TH ST SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6773
Mailing Address - Country:US
Mailing Address - Phone:425-967-0051
Mailing Address - Fax:
Practice Address - Street 1:4320 196TH ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6773
Practice Address - Country:US
Practice Address - Phone:425-967-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160033940225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant