Healthcare Provider Details

I. General information

NPI: 1194032201
Provider Name (Legal Business Name): JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 7TH ST STE A
PORT TOWNSEND WA
98368-2404
US

IV. Provider business mailing address

834 SHERIDAN ST
PORT TOWNSEND WA
98368-2443
US

V. Phone/Fax

Practice location:
  • Phone: 360-379-0477
  • Fax:
Mailing address:
  • Phone: 360-385-2200
  • Fax: 360-379-2282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberHAC.FS.00000085
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberHAC.FS.00000085
License Number StateWA

VIII. Authorized Official

Name: MS. KATHY LEE PORTER
Title or Position: REGISTRATION COORDINATOR
Credential: CHAM
Phone: 360-385-2200