Healthcare Provider Details

I. General information

NPI: 1205793395
Provider Name (Legal Business Name): JEREMY GLENN NUGENT CM60686561
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAY NUGENT CM60686561

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 STEELHAMMER DR
CENTRALIA WA
98531-1532
US

IV. Provider business mailing address

10503 CREEK ST SE UNIT 115
YELM WA
98597-8678
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-8056
  • Fax: 360-623-1072
Mailing address:
  • Phone: 360-623-8056
  • Fax: 360-623-1072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberCM6066561
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: