Basic Information
| Provider Information | |||||||||
| NPI: | 1487056511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENINO FAMILY PRACTICE PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEYTON JUMP MD SOLE MEMBER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4020 | ||||||||
| Address2: | |||||||||
| City: | TENINO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985894020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602645665 | ||||||||
| FaxNumber: | 3602645666 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 SUSSEX AVE E | ||||||||
| Address2: | |||||||||
| City: | TENINO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985899359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602645665 | ||||||||
| FaxNumber: | 3602645666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2014 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | JUMP | ||||||||
| AuthorizedOfficialFirstName: | LEYTON | ||||||||
| AuthorizedOfficialMiddleName: | ENDICOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3602645665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | MD00022762 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine |
No ID Information.