Provider Demographics
NPI:1609983972
Name:BREIDENBACH, JACALYN (MPT)
Entity type:Individual
Prefix:
First Name:JACALYN
Middle Name:
Last Name:BREIDENBACH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JACALYN
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2515 140TH AVE NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-1862
Mailing Address - Country:US
Mailing Address - Phone:425-644-4100
Mailing Address - Fax:425-644-4101
Practice Address - Street 1:126 15TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3409
Practice Address - Country:US
Practice Address - Phone:253-445-8663
Practice Address - Fax:253-445-8342
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0140283OtherL&I
WA8332975Medicaid
WA8332975Medicaid