| NPI |
1437933454 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Entity Type Code |
1 |
The date that a record was last updated or changed. |
| Provider Last Name Legal Name |
DAVIDSON |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Provider First Name |
JILL |
The first name of the authorized official. |
| Provider Middle Name |
MARIE |
The title or position of the authorized official. |
| Provider Credential Text |
MSOT, OTR/L |
The 10-position telephone number of the authorized official. |
| Provider First Line Business Practice Location Address |
12121 HARBOUR REACH DR STE 100 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider Business Practice Location Address City Name |
MUKILTEO |
|
| Provider Business Practice Location Address State Name |
WA |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Provider Business Practice Location Address Postal Code |
982755314 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
|
| Provider Business Practice Location Address Telephone Number |
3605251710 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
8/21/2023 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
8/21/2023 |
The date that a record was last updated or changed. |
| Provider Gender Code |
F |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
225XH1200X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| NPI Certification Date |
8/21/2023 |
|