Provider Demographics
NPI:1801407002
Name:FONSECA, JUTTA (MA61091263)
Entity type:Individual
Prefix:
First Name:JUTTA
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MA61091263
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 LACEY BLVD SE # 5885
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2459
Mailing Address - Country:US
Mailing Address - Phone:253-678-0598
Mailing Address - Fax:
Practice Address - Street 1:8604 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-2008
Practice Address - Country:US
Practice Address - Phone:253-678-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61091263225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty