Basic Information
| Provider Information | |||||||||
| NPI: | 1912927815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JADE | ||||||||
| FirstName: | KLAUS | ||||||||
| MiddleName: | BERNHARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604866508 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205A LILLY RD NE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604594163 | ||||||||
| FaxNumber: | 3604568155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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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 | 207N00000X | MD00028011 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1090935 | 05 | WA | MEDICAID |