1770897274 NPI number — JEREMY CORNWELL DPT

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770897274 NPI number — JEREMY CORNWELL DPT

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CORNWELL

Provider First Name:

JEREMY

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DPT

Provider Gender Code:

M

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:

1770897274

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/14/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 940

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CLINTON

Provider Business Mailing Address State Name:

WA

Provider Business Mailing Address Postal Code:

98236-0940

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

360-341-1731

Provider Business Mailing Address Fax Number:

360-341-1053

Provider First Line Business Practice Location Address:

8786 STATE ROUTE 525

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CLINTON

Provider Business Practice Location Address State Name:

WA

Provider Business Practice Location Address Postal Code:

98236

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

360-341-1731

Provider Business Practice Location Address Fax Number:

360-341-1053

Provider Enumeration Date:

07/27/2010

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:  PT60041805 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0598CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0695CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: P00893790 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0266242 . This is a "DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0266279 . This is a "DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0597CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0603CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0605CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0266257 . This is a "DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0599CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 0645CO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".