Provider Demographics
NPI:1043228422
Name:KAUFMAN, JEDEDIAH A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEDEDIAH
Middle Name:A
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5025
Mailing Address - Country:US
Mailing Address - Phone:360-493-5252
Mailing Address - Fax:360-459-6543
Practice Address - Street 1:19930 BALLINGER WAY NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155
Practice Address - Country:US
Practice Address - Phone:425-778-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042902208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00042902OtherSTATE LICENSE
I07211Medicare UPIN