Healthcare Provider Details

I. General information

NPI: 1376165571
Provider Name (Legal Business Name): JACILYN KAY T HERR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 FAWCETT AVE
TACOMA WA
98402-5502
US

IV. Provider business mailing address

1510 N MULLEN ST
TACOMA WA
98406-3302
US

V. Phone/Fax

Practice location:
  • Phone: 253-355-9866
  • Fax:
Mailing address:
  • Phone: 253-414-2867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: