Provider Demographics
NPI:1134867716
Name:MASSART, JEFFREY JAMES
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
Last Name:MASSART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S. WESTERN AVE
Mailing Address - Street 2:C/O: CREDENTIALING
Mailing Address - City:TONASKET
Mailing Address - State:WA
Mailing Address - Zip Code:98855
Mailing Address - Country:US
Mailing Address - Phone:509-486-3144
Mailing Address - Fax:
Practice Address - Street 1:203 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:TONASKET
Practice Address - State:WA
Practice Address - Zip Code:98855-8803
Practice Address - Country:US
Practice Address - Phone:509-486-2784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60351268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003997Medicaid