Provider Demographics
NPI:1700830882
Name:CONKLIN, JEREMY HENRY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:HENRY
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:747 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4307
Mailing Address - Country:US
Mailing Address - Phone:206-215-2520
Mailing Address - Fax:206-215-6364
Practice Address - Street 1:999 N CURTIS RD STE 415
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1334
Practice Address - Country:US
Practice Address - Phone:208-302-2600
Practice Address - Fax:208-302-2625
Is Sole Proprietor?:No
Enumeration Date:2006-05-21
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP608162422086S0102X
COCDR.00021222086S0102X, 364SC0200X
IDOC-04352086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1700830882Medicaid
PAOS013779OtherSTATE LICENSE NUMBER
PABC9903128OtherDEA NUMBER
NY269916OtherSTATE