Provider Demographics
NPI:1821423369
Name:MARSHALL, JAKE ALAN (ATC)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:ALAN
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 112TH AVE NE
Mailing Address - Street 2:SUITE D-154
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3752
Mailing Address - Country:US
Mailing Address - Phone:661-373-7851
Mailing Address - Fax:
Practice Address - Street 1:1750 112TH AVE NE
Practice Address - Street 2:SUITE D-154
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3752
Practice Address - Country:US
Practice Address - Phone:661-373-7851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1 603271892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer