Provider Demographics
NPI:1336607209
Name:JOHNSTON, JESSY WAYNE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:WAYNE
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 MOTTMAN RD SW # 106
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6232
Mailing Address - Country:US
Mailing Address - Phone:360-480-1936
Mailing Address - Fax:
Practice Address - Street 1:2330 MOTTMAN RD SW # 106
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6232
Practice Address - Country:US
Practice Address - Phone:360-480-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60908834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist