Provider Demographics
NPI:1346639051
Name:JEFFERSON HEALTHCARE
Entity Type:Organization
Organization Name:JEFFERSON HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-385-2200
Mailing Address - Street 1:834 SHERIDAN ST
Mailing Address - Street 2:DEPARTMENT OF PHARMACY
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2443
Mailing Address - Country:US
Mailing Address - Phone:360-385-2200
Mailing Address - Fax:360-385-6925
Practice Address - Street 1:834 SHERIDAN ST
Practice Address - Street 2:DEPARTMENT OF PHARMACY
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2443
Practice Address - Country:US
Practice Address - Phone:360-385-2200
Practice Address - Fax:360-385-6925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60291084282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH 60291084OtherWASHINGTON STATE DEPARTMENT OF HEALTH