Healthcare Provider Details

I. General information

NPI: 1104525112
Provider Name (Legal Business Name): JERRY WOOD CHES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 REPUBLICAN ST BLDG C FLR 2 BOX : 358051
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

850 REPUBLICAN ST BLDG C FLR 2 BOX : 358051
SEATTLE WA
98195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 206-520-5584
  • Fax: 206-520-4747
Mailing address:
  • Phone: 206-520-5584
  • Fax: 206-520-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number37796
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number37796
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: