Provider Demographics
NPI:1487790754
Name:KETCHAM, JASON C (LMP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:KETCHAM
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:11821 NE 128TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7210
Practice Address - Country:US
Practice Address - Phone:425-285-1250
Practice Address - Fax:425-285-1255
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022154225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist