Provider Demographics
NPI:1255583498
Name:GILSOUL, JEREMY ELI (LAC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ELI
Last Name:GILSOUL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 N 33RD ST UNIT 26C
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2598
Mailing Address - Country:US
Mailing Address - Phone:206-669-2355
Mailing Address - Fax:
Practice Address - Street 1:7822 27TH ST W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4111
Practice Address - Country:US
Practice Address - Phone:253-243-2308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4190-046174400000X
WAAC 60487836171100000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist