Provider Demographics
NPI:1366746786
Name:WITTKOPP, JEFFREY A (PA)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:WITTKOPP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 WESTMONT PL SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3748
Mailing Address - Country:US
Mailing Address - Phone:253-967-5868
Mailing Address - Fax:253-967-5868
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-967-5868
Practice Address - Fax:253-967-5868
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092365363A00000X
WAPA61036629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant