Provider Demographics
NPI:1285857136
Name:CHUBBUCK, JIMMY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:DEAN
Last Name:CHUBBUCK
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 1:2096 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-9115
Mailing Address - Country:US
Mailing Address - Phone:360-829-6304
Mailing Address - Fax:
Practice Address - Street 1:2120 RYAN RD
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321-9115
Practice Address - Country:US
Practice Address - Phone:360-829-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA20387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1189107Medicaid
WAA08359Medicare UPIN