Healthcare Provider Details

I. General information

NPI: 1780833004
Provider Name (Legal Business Name): JENNIFER R JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 S PINE ST
TACOMA WA
98409-7264
US

IV. Provider business mailing address

4301 S PINE ST
TACOMA WA
98409-7264
US

V. Phone/Fax

Practice location:
  • Phone: 253-476-6500
  • Fax: 253-476-6547
Mailing address:
  • Phone: 253-476-6500
  • Fax: 253-476-6547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number048.0107097
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60428357
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: