Basic Information
| Provider Information | |||||||||
| NPI: | 1578575734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLINTON | ||||||||
| FirstName: | JEREMIAH | ||||||||
| MiddleName: | MALACHI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 E CENTRAL AVE STE 440 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992086290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092521977 | ||||||||
| FaxNumber: | 5094653026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ML20007417 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD00047792 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1578575734 | 05 | MT | MEDICAID | 1578575734 | 05 | WA | MEDICAID | 1578575734 | 05 | ID | MEDICAID |