Provider Demographics
NPI:1205816782
Name:HOUSE, JAMIE GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:GLEN
Last Name:HOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1315 N DIVISION ST STE A
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1899
Mailing Address - Country:US
Mailing Address - Phone:509-624-0908
Mailing Address - Fax:509-459-0881
Practice Address - Street 1:1315 N DIVISION ST STE A
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1899
Practice Address - Country:US
Practice Address - Phone:509-624-0908
Practice Address - Fax:509-459-0881
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIMLC.MD.61124854208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54701279Medicaid
CO54701279Medicaid
COC486898Medicare PIN