1235204181 NPI number — JODI W FUNK

Table of content: (NPI 1235204181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235204181 NPI number — JODI W FUNK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JODI W FUNK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235204181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2829 S GRAND BLVD
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-747-4242
Provider Business Mailing Address Fax Number:
509-747-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2829 S GRAND BLVD
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-747-4242
Provider Business Practice Location Address Fax Number:
509-747-3512
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FUNK
Authorized Official First Name:
JODI
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER PRESIDNET
Authorized Official Telephone Number:
509-747-4242

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DE00001693 , 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)

  • Identifier: 5021091 . This is a "DEPT OF SOCIAL & HEALTH S" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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