Healthcare Provider Details

I. General information

NPI: 1760949820
Provider Name (Legal Business Name): JESSICA ASHLEY SEXTON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 16TH AVE E
SEATTLE WA
98112-5226
US

IV. Provider business mailing address

9090 RAVENNA AVE NE UNIT 201
SEATTLE WA
98115-8317
US

V. Phone/Fax

Practice location:
  • Phone: 206-326-3000
  • Fax:
Mailing address:
  • Phone: 561-376-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86057820
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: