Provider Demographics
NPI:1316555725
Name:POORE, JONATHAN ELLIOTT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ELLIOTT
Last Name:POORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 HALE DR
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98651-9147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 HALE DR
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:WA
Practice Address - Zip Code:98651-9147
Practice Address - Country:US
Practice Address - Phone:831-325-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program