Healthcare Provider Details

I. General information

NPI: 1790741924
Provider Name (Legal Business Name): LEYTON ENDICOTT JUMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 SUSSEX AVE E
TENINO WA
98589-9359
US

IV. Provider business mailing address

PO BOX 4020
TENINO WA
98589-4020
US

V. Phone/Fax

Practice location:
  • Phone: 360-264-5665
  • Fax: 360-264-5666
Mailing address:
  • Phone: 360-264-5665
  • Fax: 360-264-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD00022762
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: