Healthcare Provider Details

I. General information

NPI: 1477630507
Provider Name (Legal Business Name): JAMESTOWN S'KLALLAM TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 OLD BLYN HWY
SEQUIM WA
98382-7670
US

IV. Provider business mailing address

1033 OLD BLYN HWY
SEQUIM WA
98382-7670
US

V. Phone/Fax

Practice location:
  • Phone: 360-683-1109
  • Fax: 360-683-3401
Mailing address:
  • Phone: 360-683-1109
  • Fax: 360-683-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: W. RON ALLEN
Title or Position: TRIBAL CHAIRMAN/EXECUTIVE DIRECTOR
Credential:
Phone: 360-683-1109