Provider Demographics
NPI:1487655635
Name:SOUTHARD, JAMIE L (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:L
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4025
Mailing Address - Country:US
Mailing Address - Phone:360-488-2123
Mailing Address - Fax:360-404-3906
Practice Address - Street 1:113 S 11TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4025
Practice Address - Country:US
Practice Address - Phone:360-488-2123
Practice Address - Fax:360-404-3906
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034154111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8346116Medicaid
WAGAB32578Medicare ID - Type Unspecified
WA8346116Medicaid