Provider Demographics
NPI:1154196624
Name:FAHEY, JORDAN MARIE (ACSM-CEP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:FAHEY
Suffix:
Gender:F
Credentials:ACSM-CEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 N VILLARD ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 5TH ST SE STE 2500
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4692
Practice Address - Country:US
Practice Address - Phone:253-381-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1074648224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist