Provider Demographics
NPI:1679596365
Name:COCHEBA, JAY RANDALL (DPM)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:RANDALL
Last Name:COCHEBA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4503
Mailing Address - Country:US
Mailing Address - Phone:360-424-4466
Mailing Address - Fax:360-208-0564
Practice Address - Street 1:1617 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4503
Practice Address - Country:US
Practice Address - Phone:360-424-4466
Practice Address - Fax:360-208-0564
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000773213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0264542OtherL&I
WA1016127Medicaid
WA0264542OtherL&I