Provider Demographics
NPI:1790741924
Name:JUMP, LEYTON ENDICOTT
Entity Type:Individual
Prefix:
First Name:LEYTON
Middle Name:ENDICOTT
Last Name:JUMP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4020
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-4020
Mailing Address - Country:US
Mailing Address - Phone:360-264-5665
Mailing Address - Fax:360-264-5666
Practice Address - Street 1:273 SUSSEX AVE E
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9359
Practice Address - Country:US
Practice Address - Phone:360-264-5665
Practice Address - Fax:360-264-5666
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022762208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1005719Medicaid
WA90836OtherLABOR & INDUSTRIES
G8856183OtherPTAN
G8856183OtherMEDICARE
T01236OtherREGENCE
101589OtherBLACK LUNG
A08291Medicare UPIN