Basic Information
| Provider Information | |||||||||
| NPI: | 1134488794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERY | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 11216 SUNRISE BLVD E | ||||||||
| Address2: | # 3-106 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538485951 | ||||||||
| FaxNumber: | 2538457073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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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 | 207Q00000X | OP60413252 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2022097 | 05 | WA | MEDICAID |