1205793395 NPI number — JEREMY GLENN NUGENT CM60686561

Table of content: JEREMY GLENN NUGENT CM60686561 (NPI 1205793395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205793395 NPI number — JEREMY GLENN NUGENT CM60686561

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUGENT
Provider First Name:
JEREMY
Provider Middle Name:
GLENN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CM60686561
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NUGENT
Provider Other First Name:
JAY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CM60686561
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1205793395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10503 CREEK ST SE UNIT 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YELM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98597-8678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-623-8056
Provider Business Mailing Address Fax Number:
360-623-1072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 STEELHAMMER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-623-8056
Provider Business Practice Location Address Fax Number:
360-623-1072
Provider Enumeration Date:
01/08/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  CM6066561 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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