Provider Demographics
NPI:1972832855
Name:GELDERLOOS, JAN (LMT, NMT)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:
Last Name:GELDERLOOS
Suffix:
Gender:M
Credentials:LMT, NMT
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 48142
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98148-0142
Mailing Address - Country:US
Mailing Address - Phone:206-935-7526
Mailing Address - Fax:
Practice Address - Street 1:4101 W MARGINAL WAY SW
Practice Address - Street 2:A4
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-1282
Practice Address - Country:US
Practice Address - Phone:206-935-7526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00006764174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0206602OtherLABOR AND INDUSTRIES, WA