Provider Demographics
NPI:1215272588
Name:RENSHAW, JORDAN BRIE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BRIE
Last Name:RENSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8312 320TH ST S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:WA
Mailing Address - Zip Code:98580-8787
Mailing Address - Country:US
Mailing Address - Phone:253-508-3059
Mailing Address - Fax:
Practice Address - Street 1:24837 104TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6800
Practice Address - Country:US
Practice Address - Phone:253-854-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60281094173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist