Provider Demographics
NPI:1760546139
Name:SCANLON, JEROME E (PT)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:E
Last Name:SCANLON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22007 MARINE VIEW DR S
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6259
Mailing Address - Country:US
Mailing Address - Phone:206-592-0568
Mailing Address - Fax:206-592-0583
Practice Address - Street 1:22007 MARINE VIEW DR S
Practice Address - Street 2:SUITE 203
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6259
Practice Address - Country:US
Practice Address - Phone:206-592-0568
Practice Address - Fax:206-592-0583
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist