Provider Demographics
NPI:1457987992
Name:KRUSE, JACK ROBERT (SUDPT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ROBERT
Last Name:KRUSE
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10514 NE 144TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-5250
Mailing Address - Country:US
Mailing Address - Phone:206-384-7769
Mailing Address - Fax:
Practice Address - Street 1:16715 AURORA AVE N STE 102
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5310
Practice Address - Country:US
Practice Address - Phone:206-546-9766
Practice Address - Fax:206-542-0326
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program