Provider Demographics
NPI:1952872764
Name:LEAPOLDT, JACK (LMP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LEAPOLDT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18222 NE 207TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-9751
Mailing Address - Country:US
Mailing Address - Phone:720-771-8347
Mailing Address - Fax:
Practice Address - Street 1:1207 SE RASMUSSEN BLVD STE 119
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-8618
Practice Address - Country:US
Practice Address - Phone:360-842-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60866250225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist