Provider Demographics
NPI:1225047566
Name:JEROME, JEROME T III (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:T
Last Name:JEROME
Suffix:III
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 1:817 COMMERCIAL STREET
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-1316
Mailing Address - Country:US
Mailing Address - Phone:509-548-3431
Mailing Address - Fax:509-548-2510
Practice Address - Street 1:817 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-1316
Practice Address - Country:US
Practice Address - Phone:509-548-3431
Practice Address - Fax:509-548-2510
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036567207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA260172OtherDEPARTMENT OF LABOR & INDUSTRIES
WA8240475Medicaid
WA456484OtherDEPARTMENT OF LABOR & INDUSTRIES
WAG8894617Medicaid
WAG92931Medicare UPIN