Healthcare Provider Details

I. General information

NPI: 1760989990
Provider Name (Legal Business Name): JENNA ROSE WIXON GENACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195
US

IV. Provider business mailing address

325 9TH AVE # 359895
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-3300
  • Fax:
Mailing address:
  • Phone: 206-744-2155
  • Fax: 206-744-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61087147
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: