Healthcare Provider Details

I. General information

NPI: 1972832855
Provider Name (Legal Business Name): JAN GELDERLOOS LMT, NMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 W MARGINAL WAY SW A4
SEATTLE WA
98106-1282
US

IV. Provider business mailing address

PO BOX 48142
SEATTLE WA
98148-0142
US

V. Phone/Fax

Practice location:
  • Phone: 206-935-7526
  • Fax:
Mailing address:
  • Phone: 206-935-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA 00006764
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: