Leyton Endicott Jump
Individual provider Active NPI General Practice Physician · Tenino, WA
NPI 1790741924 · NPPES record last updated Feb 26, 2015
Key facts
- NPI
- 1790741924
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Physician 208D00000X
- License
- MD00022762 (WA)
- Practice address
- 273 Sussex Ave E
Tenino, WA 98589-9359 - Phone
- (360) 264-5665
- Fax
- (360) 264-5666
- NPI assigned
- Apr 25, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150626001385 | WA | Practitioner - General Practice |
7911970207 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lewis County Community Health Services | Current | Accepting new patients | |
| Lewis County Community Health Services | Current |
Accepting new patients |
Locations
2690 NE Kresky Ave
Chehalis, WA 98532
Phone (360) 330-9595
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Physician | 208D00000X | MD00022762 | WA | Yes |
Addresses
Primary practice location
273 Sussex Ave E
Tenino, WA 98589-9359
Mailing address
PO Box 4020
Tenino, WA 98589-4020
Phone (360) 264-5665
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1005719 | Medicaid | WA | |
| 90836 | Other | WA | LABOR & INDUSTRIES |
| G8856183 | Other | PTAN | |
| G8856183 | Other | MEDICARE | |
| T01236 | Other | REGENCE | |
| 101589 | Other | BLACK LUNG |
Other providers in Tenino, WA
- Jessica Hemley
- Irene Fern Hunter
- Chasity Daugherty7 Johnson
- Shirley Jeanne Johnson
- Shelley L Jones
- Annette Kissel
- Lewis County Community Health Services
- Leyton Endicott Jump
- Massage Therapy by Magic Inc
- Morgan Taylor Masters
All providers in Tenino, WA · General Practice Physician in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 26, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.