Healthcare Provider Details

I. General information

NPI: 1922360940
Provider Name (Legal Business Name): JENNIFER ELLYN SOUDERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6808 220TH ST SW NORTH START PLACE, STE 201
MOUNTLAKE TERRACE WA
98043-2187
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-6976
  • Fax: 425-640-6977
Mailing address:
  • Phone: 206-264-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD00029678
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD00029678
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: