Provider Demographics
NPI:1679631436
Name:CALVERT, JACK (ARNP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CALVERT
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-9478
Mailing Address - Country:US
Mailing Address - Phone:509-698-3318
Mailing Address - Fax:
Practice Address - Street 1:401 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-9478
Practice Address - Country:US
Practice Address - Phone:509-698-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30002093OtherSTATE OF WA ARNP LICENSE