Basic Information
| Provider Information | |||||||||
| NPI: | 1093128027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JADERHOLM | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | WELLS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3649 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992203649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098382531 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1326 N STANFORD LN | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990195034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098382531 | ||||||||
| FaxNumber: | 5097556580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 58.007627 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OP60804314 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0159060 | 05 | OH | MEDICAID |