Provider Demographics
NPI:1134521016
Name:JEFFRIES, JAY RUSSELL (LMP)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:RUSSELL
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 EVERGREEN POINT RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:WA
Mailing Address - Zip Code:98039-2342
Mailing Address - Country:US
Mailing Address - Phone:808-561-1710
Mailing Address - Fax:206-299-3436
Practice Address - Street 1:2229 EVERGREEN POINT RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:WA
Practice Address - Zip Code:98039-2342
Practice Address - Country:US
Practice Address - Phone:808-561-1710
Practice Address - Fax:206-299-3436
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA0008469225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist