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General NPI Number Information
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NPI Number | 1730984303
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Entity Type | Individual
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Provider Name | ETHAN JETT WILMOVSKY DC
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Gender | Male
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Dates
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Enumeration Date | 02/17/2025
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 2627 CAPITAL MALL DR SW # B-3A
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City | OLYMPIA
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State | WA
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Zip | 98502-8696
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Country | US
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Telephone | 360-786-6322
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Fax |
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Provider Business Mailing Address
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Address Line | 704 DENNIS ST SE
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City | TUMWATER
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State | WA
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Zip | 98501-5527
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Country | US
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Telephone | 360-481-0544
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 61662847
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License Number State | WA
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