Provider Demographics
NPI:1093298986
Name:MEDINA, JAIME ALFREDO (DC)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:ALFREDO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-0504
Mailing Address - Country:US
Mailing Address - Phone:509-829-5757
Mailing Address - Fax:509-829-5051
Practice Address - Street 1:607 1ST AVE
Practice Address - Street 2:
Practice Address - City:ZILLAH
Practice Address - State:WA
Practice Address - Zip Code:98953-9433
Practice Address - Country:US
Practice Address - Phone:509-829-5757
Practice Address - Fax:509-829-5051
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60888143111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH60888143OtherSTATE LICENSE