Basic Information
| Provider Information | |||||||||
| NPI: | 1790741924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUMP | ||||||||
| FirstName: | LEYTON | ||||||||
| MiddleName: | ENDICOTT | ||||||||
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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: | 04/25/2006 | ||||||||
| LastUpdateDate: | 02/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD00022762 | WA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1005719 | 05 | WA | MEDICAID | 90836 | 01 | WA | LABOR & INDUSTRIES | OTHER | G8856183 | 01 | PTAN | OTHER | G8856183 | 01 | MEDICARE | OTHER | T01236 | 01 | REGENCE | OTHER | 101589 | 01 | BLACK LUNG | OTHER |