Healthcare Provider Details

I. General information

NPI: 1790721736
Provider Name (Legal Business Name): JEFFREY CLARK ERNST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23511 56TH AVE W STE 105
MOUNTLAKE TERRACE WA
98043-5285
US

IV. Provider business mailing address

23511 56TH AVE W STE 105
MOUNTLAKE TERRACE WA
98043-5285
US

V. Phone/Fax

Practice location:
  • Phone: 206-546-2421
  • Fax: 206-542-9028
Mailing address:
  • Phone: 206-546-2421
  • Fax: 206-542-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38513
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: