=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649117474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROME TYRRELL JEROME IV EMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2026
-----------------------------------------------------
Last Update Date | 04/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 913 KOALA DR
-----------------------------------------------------
City | OMAK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98841-9576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-663-4602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12310 VILLAGE VIEW DR
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98826-9169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-881-1123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146N00000X
-----------------------------------------------------
Taxonomy Name | Basic Emergency Medical Technician
-----------------------------------------------------
License Number | EMS.ES.70111053
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------