Healthcare Provider Details

I. General information

NPI: 1013995976
Provider Name (Legal Business Name): JENNIE G HENDRIE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 204TH AVE E SUITE 1300
BONNEY LAKE WA
98391-6535
US

IV. Provider business mailing address

1706 MERIDIAN S SUITE 120
PUYALLUP WA
98371-7516
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-8797
  • Fax: 253-826-1264
Mailing address:
  • Phone: 253-848-8797
  • Fax: 253-446-3239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00036248
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: