MEDICARE: DR. JAMIE L SOUTHARD DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH00034154	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487655635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE L SOUTHARD DC

Provider Business Mailing Address
First Line	:	113 S 11TH ST
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-4025
Country	:	US
Telephone Number	:	360-488-2123
Fax Number	:	360-404-3906

Provider Business Practice Location Address
First Line	:	113 S 11TH ST
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-4025
Country	:	US
Telephone Number	:	360-488-2123
Fax Number	:	360-404-3906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	11/13/2024

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