Provider Demographics
NPI:1386631943
Name:MCKIM, JEANETTE M (PT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:M
Last Name:MCKIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:M
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5765 LITTLEROCK RD SW STE 107
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7311
Practice Address - Country:US
Practice Address - Phone:564-999-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008796225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0208917OtherDEPT. OF LABOR & INDUSTRY
WA6572TOOtherREGENCE
WAP00428344OtherRAILROAD MEDICARE
WA3686TOOtherREGENCE
WA8455016Medicaid
WA3246TOOtherREGENCE
WA710883456-98502-A002OtherTRICARE
WA7393456OtherAETNA
WA4035TOOtherREGENCE BLUE SHIELD
WA5682TOOtherREGENCE
WA4035TOOtherREGENCE BLUE SHIELD