Provider Demographics
NPI:1700967445
Name:WEIDER, JERRY THOMAS JR (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:THOMAS
Last Name:WEIDER
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5429 RUSSELL AVE NW STE 300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4010
Mailing Address - Country:US
Mailing Address - Phone:206-783-6000
Mailing Address - Fax:206-783-6006
Practice Address - Street 1:5429 RUSSELL AVE NW STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4010
Practice Address - Country:US
Practice Address - Phone:206-783-6000
Practice Address - Fax:206-783-6006
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020592Medicaid
WA2020592Medicaid
WAU59358Medicare UPIN