=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598056996
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY C. HSU PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2011
-----------------------------------------------------
Last Update Date | 04/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 TERRA EDEN ST
-----------------------------------------------------
City | FORKS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98331-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-374-6868
-----------------------------------------------------
Fax | 360-374-6870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 TERRA EDEN ST
-----------------------------------------------------
City | FORKS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98331-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-374-6868
-----------------------------------------------------
Fax | 360-374-6870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT
-----------------------------------------------------
Name | KAREN CROUSE
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 360-457-3303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10147
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------