Provider Demographics
NPI:1912927815
Name:JADE, KLAUS BERNHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KLAUS
Middle Name:BERNHARD
Last Name:JADE
Suffix:
Gender:M
Credentials:MD
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 3360
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:360-486-6508
Mailing Address - Fax:
Practice Address - Street 1:205A LILLY RD NE
Practice Address - Street 2:SUITE 2
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5069
Practice Address - Country:US
Practice Address - Phone:360-459-4163
Practice Address - Fax:360-456-8155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028011207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1090935Medicaid
WAG115000412Medicare ID - Type Unspecified
WA1090935Medicaid