Provider Demographics
NPI:1487056511
Name:TENINO FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:TENINO FAMILY PRACTICE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEYTON
Authorized Official - Middle Name:ENDICOTT
Authorized Official - Last Name:JUMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-264-5665
Mailing Address - Street 1:PO BOX 4020
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-4020
Mailing Address - Country:US
Mailing Address - Phone:360-264-5665
Mailing Address - Fax:360-264-5666
Practice Address - Street 1:273 SUSSEX AVE E
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9359
Practice Address - Country:US
Practice Address - Phone:360-264-5665
Practice Address - Fax:360-264-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022762207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty