Provider Demographics
NPI:1386119709
Name:CROSSFUNCTION SPORTS MASSAGE
Entity type:Organization
Organization Name:CROSSFUNCTION SPORTS MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAPES
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:425-418-8588
Mailing Address - Street 1:2510 164TH ST SW APT F107
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-7839
Mailing Address - Country:US
Mailing Address - Phone:425-772-5671
Mailing Address - Fax:
Practice Address - Street 1:16000 BOTHELL EVERETT HWY STE 161
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1742
Practice Address - Country:US
Practice Address - Phone:425-595-3436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1316476112Medicaid