Provider Demographics
NPI:1366097222
Name:DEJONG, MARISSA (DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DEJONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:LEDUC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 E 2ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8815 E MISSION AVE STE A
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99212-5039
Practice Address - Country:US
Practice Address - Phone:509-444-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60927113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist