Provider Demographics
NPI:1114913613
Name:PAYNE, JERRY M (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:PAYNE
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 1:1217 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4301
Mailing Address - Country:US
Mailing Address - Phone:360-452-3017
Mailing Address - Fax:360-452-4100
Practice Address - Street 1:1217 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4301
Practice Address - Country:US
Practice Address - Phone:360-452-3017
Practice Address - Fax:360-452-4100
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022861Medicaid
WA124952OtherL AND I
WAG8851006OtherMEDICARE GROUP PIN
U71990Medicare UPIN
WAG8851005Medicare PIN