Provider Demographics
NPI:1356197552
Name:JORGENSEN, TRISTAN R
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:R
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-3529
Mailing Address - Country:US
Mailing Address - Phone:425-698-5999
Mailing Address - Fax:
Practice Address - Street 1:1200 HARRIS AVE STE 405
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7146
Practice Address - Country:US
Practice Address - Phone:425-698-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist