Provider Demographics
NPI:1003429291
Name:RUPP, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:RUPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 LAKE WASHINGTON BLVD N APT K101
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1455
Mailing Address - Country:US
Mailing Address - Phone:315-486-2596
Mailing Address - Fax:
Practice Address - Street 1:2100 LAKE WASHINGTON BLVD N APT K101
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-1455
Practice Address - Country:US
Practice Address - Phone:315-486-2596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61082905225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist