Provider Demographics
NPI:1699249946
Name:CARTER, JESSICA KYLIE (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KYLIE
Last Name:CARTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15602 NE 78TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3510
Mailing Address - Country:US
Mailing Address - Phone:720-545-6242
Mailing Address - Fax:
Practice Address - Street 1:3021 NE 72ND DR STE 5
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7300
Practice Address - Country:US
Practice Address - Phone:360-869-0212
Practice Address - Fax:360-260-4849
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60796424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist