MEDICARE: MR. JERRY CHRISTOPHER PORTER L.M.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00010465	WA

General Provider Information

NPI Number	:	1497893317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY CHRISTOPHER PORTER L.M.P.

Provider Business Mailing Address
First Line	:	2015 13TH AVE W
Second Line	:	#201
City	:	SEATTLE
State	:	WA
Zip	:	98119-2773
Country	:	US
Telephone Number	:	206-947-0450
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 13TH AVE W
Second Line	:	#201
City	:	SEATTLE
State	:	WA
Zip	:	98119-2702
Country	:	US
Telephone Number	:	206-947-0450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	05/23/2008

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