Provider Demographics
NPI:1851357008
Name:LEYTON ENDICOTT JUMP
Entity Type:Organization
Organization Name:LEYTON ENDICOTT JUMP
Other - Org Name:TENINO FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEYTON
Authorized Official - Middle Name:ENDICOTT
Authorized Official - Last Name:JUMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-264-5665
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA122559OtherLABOR & INDUSTRIES
WA7102478Medicaid
WAG8856180Medicare PIN
503857Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC