Healthcare Provider Details

I. General information

NPI: 1902804594
Provider Name (Legal Business Name): JAYME T. MACKAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1271 HIGHLAND AVE SUITE A
CLARKSTON WA
99403-2846
US

IV. Provider business mailing address

1271 HIGHLAND AVE SUITE A
CLARKSTON WA
99403-2846
US

V. Phone/Fax

Practice location:
  • Phone: 509-751-1500
  • Fax: 509-751-1504
Mailing address:
  • Phone: 509-751-1500
  • Fax: 509-751-1504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35944
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: