Healthcare Provider Details

I. General information

NPI: 1083141725
Provider Name (Legal Business Name): JEREMY ESPELETA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32200 MILITARY RD S APT P103
FEDERAL WAY WA
98001-9627
US

IV. Provider business mailing address

32200 MILITARY RD S APT P103
FEDERAL WAY WA
98001
US

V. Phone/Fax

Practice location:
  • Phone: 907-738-5241
  • Fax:
Mailing address:
  • Phone: 907-738-5241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP1 60736171
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: