Healthcare Provider Details

I. General information

NPI: 1720124357
Provider Name (Legal Business Name): JENNIFER LEE DERHAM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEE BERTAGNI DPT

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7728 204TH ST. NE #A
ARLINGTON WA
98223
US

IV. Provider business mailing address

11453 E REUBEN AVE
MESA AZ
85212-4113
US

V. Phone/Fax

Practice location:
  • Phone: 360-403-8250
  • Fax: 360-403-0917
Mailing address:
  • Phone: 425-750-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7452
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00010288
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: