Healthcare Provider Details

I. General information

NPI: 1194119115
Provider Name (Legal Business Name): JONATHAN PAUL BERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4265
US

IV. Provider business mailing address

209 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4265
US

V. Phone/Fax

Practice location:
  • Phone: 253-596-3300
  • Fax: 253-596-3301
Mailing address:
  • Phone: 253-596-3300
  • Fax: 253-596-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML60562628
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD60847137
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: