Provider Demographics
NPI:1871730648
Name:HIATT, JESSICA ROSE LOUISE (LMP)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ROSE LOUISE
Last Name:HIATT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:ROSE LOUISE
Other - Last Name:MCSPADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:2562 S WILBUR AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-8705
Mailing Address - Country:US
Mailing Address - Phone:509-240-4424
Mailing Address - Fax:
Practice Address - Street 1:120 E BIRCH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3054
Practice Address - Country:US
Practice Address - Phone:509-240-4424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00024905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist