Healthcare Provider Details

I. General information

NPI: 1740776046
Provider Name (Legal Business Name): JORDAN KUMASAKA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 12TH ST SE
AUBURN WA
98002-6708
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 253-735-3606
  • Fax: 253-351-9807
Mailing address:
  • Phone: 253-735-3606
  • Fax: 253-351-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: