1386631943 NPI number — JEANETTE M MCKIM PT

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386631943 NPI number — JEANETTE M MCKIM PT

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MCKIM

Provider First Name:

JEANETTE

Provider Middle Name:

M

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

PT

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

CLARKE

Provider Other First Name:

JEANETTE

Provider Other Middle Name:

M

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

PT

Provider Other Last Name Type Code:

1

NPI Number:

1386631943

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/14/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1200 CORPORATE DR STE 400

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

HOOVER

Provider Business Mailing Address State Name:

AL

Provider Business Mailing Address Postal Code:

35242-5424

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

5765 LITTLEROCK RD SW STE 107

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

TUMWATER

Provider Business Practice Location Address State Name:

WA

Provider Business Practice Location Address Postal Code:

98512-7311

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

564-999-4146

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

09/29/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 225100000X , with the licence number:  PT00008796 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0208917 . This is a "DEPT. OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 6572TO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: P00428344 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 3686TO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 8455016 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 3246TO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 710883456-98502-A002 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 7393456 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 4035TO . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 5682TO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".