Healthcare Provider Details

I. General information

NPI: 1114498755
Provider Name (Legal Business Name): JENNI ANNE MCMILLAN SUDPT, PEER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNI ANNE MCMILLAN CO-60788153

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 TACOMA AVE S STE 305
TACOMA WA
98402-1903
US

IV. Provider business mailing address

1305 TACOMA AVE S STE 305
TACOMA WA
98402-1903
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-5000
  • Fax:
Mailing address:
  • Phone: 253-396-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: