Provider Demographics
NPI:1205922796
Name:WALLERICH, JENNIFER C (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:WALLERICH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-6304
Mailing Address - Country:US
Mailing Address - Phone:206-631-2818
Mailing Address - Fax:206-631-2819
Practice Address - Street 1:925 8TH AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-6304
Practice Address - Country:US
Practice Address - Phone:206-631-2818
Practice Address - Fax:206-631-2819
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8862215Medicare PIN