Provider Demographics
NPI:1356758668
Name:STANLEY, JEROD (DPM)
Entity type:Individual
Prefix:
First Name:JEROD
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 ENSIGN RD NE STE N
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5065
Mailing Address - Country:US
Mailing Address - Phone:360-943-9600
Mailing Address - Fax:360-943-9694
Practice Address - Street 1:3525 ENSIGN RD NE STE N
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5065
Practice Address - Country:US
Practice Address - Phone:360-943-9600
Practice Address - Fax:360-943-9694
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60750804213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist