=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659509727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA CRAIK MACDONALD DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 09/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1313 BROADWAY STE 200
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98402-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-301-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5224 336TH AVE SE
-----------------------------------------------------
City | FALL CITY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98024-9654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-935-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT38739
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT60231770
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------