Healthcare Provider Details

I. General information

NPI: 1104746833
Provider Name (Legal Business Name): JAMIE WOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CONSTELLATION AUTUMN

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 MARTIN WAY E STE 211
OLYMPIA WA
98506-6707
US

IV. Provider business mailing address

522 W RIVERSIDE AVE # 8161
SPOKANE WA
99201-0580
US

V. Phone/Fax

Practice location:
  • Phone: 360-890-8964
  • Fax:
Mailing address:
  • Phone: 360-355-8469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: