Provider Demographics
NPI:1992251201
Name:JERDES, THEODORE BASIL (LMP)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:BASIL
Last Name:JERDES
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 1:1210 SLEATER KINNEY RD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2316
Mailing Address - Country:US
Mailing Address - Phone:360-352-4511
Mailing Address - Fax:360-754-4703
Practice Address - Street 1:1210 SLEATER KINNEY RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2316
Practice Address - Country:US
Practice Address - Phone:360-352-4511
Practice Address - Fax:360-754-4703
Is Sole Proprietor?:No
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60597586174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist