Provider Demographics
NPI:1356492953
Name:JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Entity Type:Organization
Organization Name:JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Other - Org Name:JEFFERSON HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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:
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:360-379-4381
Practice Address - Street 1:834 SHERIDAN ST
Practice Address - Street 2:
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:360-379-4381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
WA282NC0060X282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7173404Medicaid
WA8865428OtherMEDICARE PTAN
WA3301900Medicaid
WA3301900Medicaid
WAG000250200Medicare PIN