Healthcare Provider Details

I. General information

NPI: 1285686261
Provider Name (Legal Business Name): JENNELLE MARCEREAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COLBY AVE
EVERETT WA
98201-1665
US

IV. Provider business mailing address

10514 60TH AVE W
MUKILTEO WA
98275-4676
US

V. Phone/Fax

Practice location:
  • Phone: 425-261-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberOP00001935
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: