Basic Information
| Provider Information | |||||||||
| NPI: | 1386631943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKIM | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARKE | ||||||||
| OtherFirstName: | JEANETTE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5765 LITTLEROCK RD SW STE 107 | ||||||||
| Address2: | |||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985127311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5649994146 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008796 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0208917 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 6572TO | 01 | WA | REGENCE | OTHER | P00428344 | 01 | WA | RAILROAD MEDICARE | OTHER | 3686TO | 01 | WA | REGENCE | OTHER | 8455016 | 05 | WA | MEDICAID | 3246TO | 01 | WA | REGENCE | OTHER | 710883456-98502-A002 | 01 | WA | TRICARE | OTHER | 7393456 | 01 | WA | AETNA | OTHER | 4035TO | 01 | WA | REGENCE BLUE SHIELD | OTHER | 5682TO | 01 | WA | REGENCE | OTHER |