Healthcare Provider Details

I. General information

NPI: 1669057725
Provider Name (Legal Business Name): JORDANN MICHELLE HOFSTRAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 NE PROVIDENCE CT APT O301
PULLMAN WA
99163-5788
US

IV. Provider business mailing address

18031 77TH ST E
BONNEY LAKE WA
98391
US

V. Phone/Fax

Practice location:
  • Phone: 253-350-5758
  • Fax:
Mailing address:
  • Phone: 253-350-5758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: