Active NPI
Theodore Basil Jerdes, LMP
- Specialist
- Lacey, WA
National Provider Identifier
1992251201
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Specialist
- License
- MA 60597586
- Practice address
- 1210 Sleater Kinney Rd SE
Lacey, WA 98503-2316 - Phone
- (360) 352-4511
- Fax
- (360) 754-4703
- NPI assigned
- Aug 27, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | MA 60597586 | WA | Primary |
Addresses
Primary practice location
1210 Sleater Kinney Rd SE
Lacey, WA 98503-2316
Mailing address
1210 Sleater Kinney Rd SE
Lacey, WA 98503-2316
Phone (360) 352-4511
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MA 60597586 | WA | MD | Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1472256000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1472256000000",
"number": "1992251201",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1210 SLEATER KINNEY RD SE",
"city": "LACEY",
"state": "WA",
"postal_code": "985032316",
"telephone_number": "360-352-4511",
"fax_number": "360-754-4703"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1210 SLEATER KINNEY RD SE",
"city": "LACEY",
"state": "WA",
"postal_code": "985032316",
"telephone_number": "360-352-4511",
"fax_number": "360-754-4703"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JERDES",
"first_name": "THEODORE",
"middle_name": "BASIL",
"name_prefix": "Mr.",
"credential": "LMP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2016-08-27",
"last_updated": "2016-08-27",
"status": "A"
},
"taxonomies": [
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "WA",
"license": "MA 60597586",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lacey, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.