Healthcare Provider Details

I. General information

NPI: 1205477296
Provider Name (Legal Business Name): LIBERATING JASPER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2133 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-3839
US

IV. Provider business mailing address

2133 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 425-999-5812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA MCKEE
Title or Position: REGISTERED DIETITIAN, CO-FOUNDER
Credential: MS, RD
Phone: 425-999-5812