Provider Demographics
NPI:1972521672
Name:DIRKSEN, JEANNE A (PT)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:A
Last Name:DIRKSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339
Mailing Address - Country:US
Mailing Address - Phone:360-385-9310
Mailing Address - Fax:360-379-8826
Practice Address - Street 1:27 COLWELL STREET
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339
Practice Address - Country:US
Practice Address - Phone:360-385-9310
Practice Address - Fax:360-379-8826
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6147DIOtherREGENCE BLUE SHIELD
WA8374688Medicaid
WAA002OtherTRICARE WEST
WAG8862188OtherMEDICARE GROUP
WA5812580OtherAETNA
P00408657OtherRAILROAD MEDICARE PTAN
WAA002OtherTRICARE WEST
P00408657OtherRAILROAD MEDICARE PTAN