Provider Demographics
NPI:1982626487
Name:CARLSON, JEFF ROBERT (MSPT)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:ROBERT
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:425-450-9474
Mailing Address - Fax:425-635-9340
Practice Address - Street 1:11711 NE 12TH ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2461
Practice Address - Country:US
Practice Address - Phone:425-450-9474
Practice Address - Fax:425-635-9340
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
33890OtherL & I
WA7851900Medicaid
GAB38128Medicare ID - Type Unspecified