Provider Demographics
NPI:1255963856
Name:GRANDORFF, JESSICA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:GRANDORFF
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:NAPAVINE
Mailing Address - State:WA
Mailing Address - Zip Code:98565-1127
Mailing Address - Country:US
Mailing Address - Phone:360-880-9022
Mailing Address - Fax:
Practice Address - Street 1:1637 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3826
Practice Address - Country:US
Practice Address - Phone:360-880-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61035639225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist