NPIMap

Individual provider Active NPI

Benjamin Wells Jaderholm, D.O.

  • Family Medicine Physician
  • Liberty Lake, WA
National Provider Identifier
1093128027
Registry record updated Apr 27, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
OP60804314 Issued in WA
Practice address
1326 N Stanford LN
Liberty Lake, WA 99019-5034
Phone
(509) 838-2531
Fax
(509) 755-6580
NPI assigned
Jun 6, 2014
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 27, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X 58.007627 OH
Family Medicine Physician 207Q00000X OP60804314 WA Primary

Addresses

Primary practice location

1326 N Stanford LN
Liberty Lake, WA 99019-5034

Mailing address

PO Box 3649
Spokane, WA 99220-3649
Phone (509) 838-2531

Other practice location 1

100 Jackson Pike
Gallipolis, OH 45631-1560
Phone (855) 446-5937

Other practice location 2

100 Jackson Pike
Gallipolis, OH 45631-1560
Phone (855) 446-5937

Other identifiers 1

IdentifierTypeStateIssuer
0159060MedicaidOH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20180424001307 WA Practitioner - Family Practice 4789980947 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2014
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Multicare Health SystemGroup PAC ID 7719899897, 2,312 clinicians

Practice addresses (Care Compare)

1326 N Stanford LN
Liberty Lake, WA 99019-5034
Phone (509) 342-3990

311 S L St
Tacoma, WA 98405-3720

4700 Point Fosdick Dr
Gig Harbor, WA 98335-1706

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions11
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
OP60804314WAMDFamily Medicine Physician
58.007627OHMDStudent in an Organized Health Care Education/Training Program

Practice roles

OrganizationSpecialtyStatusNew patients
Multicare Health System Family Medicine CurrentSince Apr 10, 2018 Accepting new patients
Multicare Health System Current Accepting new patients
Multicare Health System CurrentSince Apr 10, 2018 Accepting new patients
Multicare Health System Family Medicine Past Accepting new patients

Locations

4700 Point Fosdick Dr
Ste 104
Gig Harbor, WA 98335
Phone (253) 459-7590

1326 N Stanford Ln
Liberty Lake, WA 99019
Phone (509) 342-3990

311 S L St
Tacoma, WA 98405
Phone (253) 403-1444

Interoperability endpoints

  • Direct secure messaging: bjaderholm336314@direct.multicare.org

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402012800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1524787200000",
    "number": "1093128027",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3649",
            "city": "SPOKANE",
            "state": "WA",
            "postal_code": "992203649",
            "telephone_number": "509-838-2531"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1326 N STANFORD LN",
            "city": "LIBERTY LAKE",
            "state": "WA",
            "postal_code": "990195034",
            "telephone_number": "509-838-2531",
            "fax_number": "509-755-6580"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "100 Jackson Pike",
            "address_purpose": "LOCATION",
            "city": "Gallipolis",
            "state": "OH",
            "postal_code": "456311560",
            "country_code": "US",
            "telephone_number": "855-446-5937",
            "fax_number": "740-446-5448",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "100 Jackson Pike",
            "address_purpose": "LOCATION",
            "city": "Gallipolis",
            "state": "OH",
            "postal_code": "456311560",
            "country_code": "US",
            "telephone_number": "855-446-5937",
            "fax_number": "740-446-5448",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JADERHOLM",
        "first_name": "BENJAMIN",
        "middle_name": "WELLS",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-06-06",
        "last_updated": "2018-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "OH",
            "license": "58.007627",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "OP60804314",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0159060",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Liberty Lake, WA

Sources for this page

Verify at the official NPI Registry.