Basic Information
| Provider Information | |||||||||
| NPI: | 1447849831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLATE | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1703 127TH PL SE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982086516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542489273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18422 103RD AVE NE | ||||||||
| Address2: | |||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980113410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259490801 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2021 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.