Provider Demographics
NPI:1427690015
Name:HIESTAND, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HIESTAND
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 1:6161 GLACIER PL
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-8321
Mailing Address - Country:US
Mailing Address - Phone:360-393-8039
Mailing Address - Fax:
Practice Address - Street 1:5320 MARK DABLING BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3839
Practice Address - Country:US
Practice Address - Phone:719-592-1584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0016676225100000X
WAPT61088902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist