Provider Demographics
NPI:1528633658
Name:VAN VALLIS, JESSICA LEE (MT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:VAN VALLIS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 100TH STREET CT S APT C
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-7360
Mailing Address - Country:US
Mailing Address - Phone:719-377-0290
Mailing Address - Fax:
Practice Address - Street 1:3901 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-4940
Practice Address - Country:US
Practice Address - Phone:253-756-7500
Practice Address - Fax:253-756-7501
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61127280225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist