=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548817844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA TRUONG PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2019
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3928 PACIFIC AVE SE
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-455-1350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15349 SW MALLARD DR STE 104
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97007-9450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 60995273
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 60995273
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------